J Clin Periodontol 2013; 40: 260–265 doi: 10.1111/jcpe.

12046

Excessive gingival display:
verson O. Silva1, Noe

Cle
V. Ribeiro-

nior2, Thiago V. S. Campos2,
Ju
Jefferson G. Rodrigues2 and Dimitris

treatment by a modified lip N. Tatakis3

1
School of Dentistry, State University of

(UEM)/Inga
University (UNINGA),

Maringa

repositioning technique Maringa
, Parana

, Brazil; 2School of Dentistry,
Alfenas Federal University (Unifal-MG),
Alfenas, Minas Gerais, Brazil; 3Division of
Periodontology, College of Dentistry, The
Ohio State University, Columbus, OH, USA
Silva CO, Ribeiro-J
unior NV, Campos TVS, Rodrigues JG, Tatakis DN. Excessive
gingival display: treatment by a modified lip repositioning technique. J Clin
Periodontol 2013; 40: 260–265. doi: 10.1111/jcpe.12046.

Abstract
Aim: The objective of this prospective study was to investigate outcomes of a lip
repositioning technique for the treatment of excessive gingival display.
Materials and Methods: Thirteen consecutively treated patients with excessive gin-
gival display were treated with a modified lip repositioning technique. Treatment
consisted of the removal of two strips of mucosa, bilaterally to the maxillary
labial frenum and coronal repositioning of the new mucosal margin. The clinical
dimensions of gingival display, upper lip and vermillion length were measured at
baseline, 3 and 6 months post-operatively. Subjects completed surveys to evaluate
satisfaction with outcomes.
Results: The baseline gingival display of 5.8  2.1 mm significantly decreased to
1.4  1.0 mm at 3 months (p < 0.0001) and was maintained until 6 months
(1.3  1.6 mm). The reduction in gingival display strongly correlated to the com-
bined change in upper lip and vermillion length (r2 = 0.60, p = 0.0018). Subjects
were satisfied with their smile after surgery and would likely choose to undergo
the procedure again (92%). The worst part of undergoing the procedure was the
discomfort or the inability to move the lip during the early healing (69%). Key words: gingiva; lips; periodontal; plastic
Conclusion: Treatment of excessive gingival display by means of a modified lip surgery; surgery
repositioning technique results in high level of patient satisfaction and predictable
outcomes that are stable in the short term. Accepted for publication 13 November 2012

Excessive gingival display, also called
“gummy smile,” is one of several
developmental or acquired deformi-
ties and conditions that manifest in
the periodontium (Armitage 1999). It
is an aesthetic issue that can affect a
large portion of the population, with
a reported prevalence between 10.5%
Conflict of interest and source of
funding statement
No external funding, apart from the
support of the authors’ institution,
was available for this study.The
authors declare that there are no con-
flicts of interest in this study.
260
(Tjan et al. 1984) and 29% (Dong
et al. 1999). Excessive gingival dis-
play is more prevalent (Peck et al.
1992, Ackerman & Ackerman 2002)
and considered more unaesthetic
(Geron & Atalia 2005) in females
than in males. Despite the high prev-
alence of excessive gingival display
and the importance of dentogingival
aesthetics with respect to self-image
and self-esteem (Paula et al. 2011),
the literature is lacking in treatment
studies.
The causes of “gummy smile”
vary; vertical maxillary excess,
anterior dentoalveolar extrusion,
altered passive eruption, short or
hyperactive upper lip, or combina-
tions thereof, are among the possible
causes (Garber & Salama 1996, Sil-
berberg et al. 2009). If the upper lip
length is within normal range and
the lower facial third is not dispro-
portionate, a hyperactive upper lip is
considered the main cause of gummy
smile. In such cases, various treat-
ment approaches have been used,
with highly variable outcomes; botu-
linum toxin (Polo 2005, Mazzuco &
Hexsel 2010), lip elongation associ-
ated with rhinoplasty (Ezquerra
et al. 1999), detachment of lip mus-
cles (Litton & Fournier 1979), myot-
omy and partial removal (Miskinyar
© 2012 John Wiley & Sons A/S

1983, Ishida et al. 2010) and lip
repositioning (Rubinstein & Kostia-
novsky 1973, Rosenblatt & Simon
2006, Simon et al. 2007) are the
reported treatment approaches.
Lip repositioning surgery consists
of the removal of a strip of mucosa
from the maxillary vestibule and
suturing the lip mucosa to the muco-
gingival line; in essence, lip reposi-
tioning is the reverse of a vestibular
extension procedure. The literature
includes only isolated case reports of
lip repositioning surgery (Rubinstein
& Kostianovsky 1973, Rosenblatt &
Simon 2006, Simon et al. 2007,
Humayun et al. 2010), with all
reports documenting good aesthetic
outcomes. The purpose of this pro-
spective study is to report the out-
comes of a modified lip repositioning
technique for the treatment of exces-
sive gingival display.
Materials and Methods
Patient population
Subjects were recruited among
patients presenting to the Periodon-
tal Clinic of Alfenas Federal Univer-
sity (Unifal-MG) for aesthetic
evaluation of their smile. The chief
complaint of the patients was the
amount of gingiva exposed during
smile.
Inclusion criteria were as follows:
adults (  18 years old), systemically
healthy, no medication intake, non-
smoker, periodontally healthy, max-
illary anterior teeth of normal
dimensions (de Castro et al. 2006),
normal upper lip length (females: 20
–22 mm; males: 22–24 mm) (Frade-
ani 2006), hyperactive upper lip (lip
mobility >8 mm) (Garber & Salama
1996) and gingival display  4 mm
during smile.
Informed consent was signed by
each of the subjects after explana-
tions on study objectives, design,
risks and potential benefits were
(a)
Fig. 1. (a) Incision design; (b) Mucosal strips removed; (c) Mucosa positioned and sutured.
© 2012 John Wiley & Sons A/S
provided. The Alfenas Federal Uni-
versity (Unifal-MG) Ethics Commit-
tee approved the experimental
protocol and consent form.
Lip repositioning surgery
The surgical treatment, performed
by a sole experienced periodontist,
consisted of a modification of the
original Rubinstein & Kostianovsky
(1973) technique, where the midline
maxillary labial frenum was not
excised. This modification was intro-
duced to facilitate maintaining the
position of the labial midline and to
reduce the morbidity associated with
the procedure.
One hour prior to surgery, patients
were given 750 mg acetaminophen
(Tylenol®; Cilag Farmac^eutica Ltda.,
S~ao Paulo, SP, Brazil) for pain man-
agement. Extra-oral and intra-oral
antisepsis was performed with 2.0%
chlorhexidine solution and 0.12%
chlorhexidine rinse for 1 min. res-
pectively (Farm
acia Escola, Alfenas
Federal University, Alfenas, MG,
Brazil). Anaesthesia was achieved by
local infiltration (2% lidocaine with
1:100.000 epinephrine) (Lidoca
ına –
Alphacaina, Adrenalina 1:100.000,
DFL Ind. E Com. Ltda, Rio de
Janeiro, RJ, Brazil).
The surgical procedure was initi-
ated at the left or right side of the
maxilla with a partial-thickness hori-
zontal incision, 1 mm coronally to
the mucogingival line, from the mid-
line frenum until the first molar
region. At each end of the first
incision, a vertical incision was
made, extending 10–12 mm apically.
Finally, a horizontal incision con-
necting the two vertical incisions,
and parallel to the first incision, was
made (Fig. 1a). The strip of out-
lined mucosa was removed by a
superficial split thickness dissection,
leaving the connective tissue
exposed. Minor salivary glands were
removed, when necessary. The
(b)
Lip repositioning surgery 261
procedure was repeated on the con-
tralateral side, leaving the midline
frenum intact (Fig. 1b). Continuous
interlocking sutures (Poligalactina 4/
0) were then used to stabilize the
new mucosal margin to the gingiva
(Fig. 1c).
Post-operative protocol
Subjects were prescribed analgesics
(acetaminophen 750 mg qid) for
2 days and instructed to use 0.12%
chlorhexidine rinse twice daily for
1 week. They were also instructed to
apply ice packs, to consume only
soft foods during the first week, to
avoid any other mechanical trauma
to the treated sites, and to minimize
lip movement when smiling or
talking during the first 2 weeks post-
operatively.
The subjects were enrolled in a
professional plaque control pro-
gramme, performed by the same
operator who provided the surgical
treatment, scheduled weekly for
the first 4 weeks, then at 3 and
6 months.
Clinical parameters
The following parameters were
assessed from clinical photographs
obtained during active smile, with a
mm ruler in place, and were recorded
at baseline, 3 and 6 months: (a)
upper lip length (from nasal base to
the superior border of the upper lip
vermillion), (b) upper lip vermillion
length (from inferior border of the
upper lip) and (c) amount of gingival
display (from the inferior border of
the upper lip vermillion to the gingi-
val margin of the central incisor).
When the lip covered part of the clin-
ical crown (post-operatively), the
amount of gingival display was set at
zero. All measurements were
recorded to the nearest millimetre
over the mid-buccal of the right cen-
tral incisor.
(c)
262 Silva et al.
(a)
(c)
Fig. 2. Representative cases before (a, c) and 6 months after (b, d) lip repositioning
surgery. Note changes in gingival display and upper lip vermillion length.
A sole trained and calibrated
examiner, not involved with treat-
ment, assessed all clinical parame-
ters. To determine examiner
reliability, parameters were measured
in triplicate over 3 weeks; the coeffi-
cient of variation for all three
parameters was  3%.
Surveys were given to the subjects
approximately 2.5 years after the
procedure. The surveys included
both Likert scale and open-ended
questions. The questions addressed
subject satisfaction with smile,
amount of gingiva displayed, symp-
toms, best and worst aspect of the
procedure and whether subject
would undergo the procedure again.
Statistical analysis
Descriptive statistics were expressed
as mean  standard deviation
(S.D.). For all parametric variables,
repeated measures ANOVA was used
for examination of mean differences
between baseline, 3 and 6 months.
Pearson correlation test was per-
formed to analyse the correlation
between the difference in gingival
display and difference in upper lip
and vermillion length. The signifi-
cance level for rejection of the null
hypothesis was set at a = 0.05.
Results
Thirteen patients, 11 females and 2
males, aged 28.7  11.0 years (range:
19–49 years), were recruited and
completed the study. Two of the
(b)
(d)
patients missed the 3-month follow-
up appointment (both were out of
town, on extended vacation). Data
from all 13 patients are reported in
the results.
Post-operative healing was
uneventful for all study participants.
Subjects complained about feeling
tension while talking and smiling,
only during the first week, and one
complained of feeling numbness. A
minor scar, not apparent during
smile, was formed on the suture line.
Upper lip length increased from
10.5  1.5 mm at baseline to 12.0 
2.8 mm at 3 months and 12.5 
2.2 mm at 6 months (p = 0.007); the
baseline lip length differed signifi-
cantly from the 6-month lip length
(p < 0.01).
Upper lip vermillion length also var-
ied significantly from 6.5  1.4 mm at
baseline to 8.6  2.2 mm at 3 months
and 8.0  1.5 mm at 6 months
(p = 0.005). The baseline vermillion
length differed significantly from both
the 3 (p < 0.01) and the 6 month
(p < 0.05) vermillion lengths, which did
not differ from each other.
Gingival display at baseline was
5.8  2.1 mm (range: 4–10 mm) and
changed significantly (p < 0.0001) at 3
and 6 months post-operatively (Fig.
2). At 3 and 6 months gingival display
was 1.4  1.0 mm (range: 0–3 mm)
and 1.3  1.6 mm (range: 0–5 mm)
respectively. The obtained reductions
of 4.7 mm (3 months) and 4.5 mm
(6 months) were significant (p < 0.01).
There was no difference in gingival
display between 3 and 6 months.
Changes in gingival display at
6 months did not correlate to changes
in lip length at the same time point
(r2 = 0.15; p = 0.19), but did correlate
to changes in vermillion length
(r2 = 0.51; p = 0.0062). In addition,
changes in gingival display correlated
most strongly to the combined change
in upper lip and vermillion length
(r2 = 0.60; p = 0.0018).
All 13 subjects completed the sur-
vey, with an average follow-up of
31  3 months. Pre-operatively, the
majority of subjects were not satis-
fied with their smile or the amount
of gingival display, while the oppo-
site was true post-operatively
(Table 1). Post-operatively, 70% of
subjects considered the amount of
displayed gingiva to be “about
right,” when pre-operatively 90%
considered it to be “way too much”
(Table 1). In contrast to the first
post-operative week, when 92% of
subjects felt very frequently (n = 10)
or frequently (n = 2) tension (pull-
ing) when talking or smiling, at
2.5 years after the procedure 85%
never felt tension and 15% did very
rarely. For most subjects (n = 9), the
worst part of undergoing the proce-
dure was the discomfort or the
inability to move the lip during the
early healing; the best part for most
subjects was the improvement of
their smile/aesthetics (n = 9) and
their improved self-esteem (n = 2).
Considering the overall experience
(the procedure, the post-operative
course and the outcome), 92% of
the subjects would likely choose to
undergo the procedure again
(Table 1).
Discussion
This prospective study aimed to
assess the outcomes of a modified lip
repositioning surgery in the treat-
ment of excessive gingival display.
The results showed that the
employed surgical procedure success-
fully reduced the pre-operative gingi-
val display in all cases, with low
morbidity. The obtained ~80% aver-
age reduction in gingival display cor-
related strongly to the combined
increase in upper lip and vermillion
length, and was stable for the
6 months of follow-up. Patient satis-
faction was high 2.5 years after the
surgery, with 70% reporting that the
post-operative amount of gingival
© 2012 John Wiley & Sons A/S

Table 1. Patient satisfaction survey responses
Question and response options
Pre-treatment (n = 13)
How satisfied are you with your smile?
Not at all satisfied
Slightly satisfied
Somewhat satisfied
Very satisfied
Extremely satisfied
How satisfied are you with the amount of gum showing when you smile?
Not at all satisfied
Slightly satisfied
Somewhat satisfied
Very satisfied
Extremely satisfied
How would you rate the amount of gum showing when you smile?
Way too little
Too little
About right
Too much
Way too much
Having had this overall experience, would you choose to have lip surgery again?
Definitely would not
Probably would not
Probably would
Definitely would
display was “about right” and more
than 90% reporting they would
likely undergo the procedure again.
To the best of our knowledge, this is
the first study to report on lip repo-
sitioning surgery clinical or patient-
centred outcomes.
Investigations have shown that
minimal gingival display during smile
is considered more attractive. Aes-
thetic perception varies depending on
social environment, personal experi-
ence and culture (Oumeish 2001,
Flores-Mir et al. 2004). Dental pro-
fessionals are usually more critical
than laypersons regarding gingival
display (Roden-Johnson et al. 2005,
Pinho et al. 2007). The amount of
gingival display that is considered
attractive varies from 1 mm (Geron
& Atalia 2005) to 3 mm (Kokich
et al. 2006). All the cases treated in
this study had baseline gingival dis-
play  4 mm. Using a criterion of
3 mm of post-operative gingival dis-
play, the modified lip repositioning
surgery was successful in 11 of the 13
cases (85% success rate) at 6 months.
Using a rather stringent criterion of
1 mm, the procedure was successful
in 10 of the 13 cases at 6 months
(77% success rate).
Although the results of lip reposi-
tioning surgery appear stable for up
to 6 months post-operatively, longer
follow-up periods are necessary to
© 2012 John Wiley & Sons A/S
Time point
Post-treatment (n = 13)
8 (62%) – play gradually increased after
4 (31%) – 2 weeks and at 24 weeks the average
1 (8%) 4 (31%)
– 6 (46%)
– 3 (23%)
7 (54%) – at 30–32 weeks post-injection (Polo
6 (46%) 1 (8%)
– 6 (46%)
– 4 (31%)
– 2 (15%)
– –
– 1 (8%)
– 9 (69%)
1 (8%) 3 (23%)
12 (92%) – smile in 14 female patients. The
– 5.22  1.48 mm was reduced to
1 (8%)
7 (54%)
5 (38%)
establish the long-term success of
this procedure. The stability of out-
comes reported in this study is con-
sistent with those of published case
reports (Rosenblatt & Simon 2006,
Simon et al. 2007, Humayun et al.
2010).
The literature is replete with case
reports of different treatment
options for “gummy smile,” depend-
ing on the aetiology, but it is lacking
in outcome studies. Only case
reports are available for the treat-
ment of delayed passive eruption
with aesthetic crown lengthening
(Borges et al. 2009) and the treat-
ment of excessive maxillary growth
with orthognathic surgery (Zahrani
2010). Outcomes for the treatment
of dentoalveolar process extrusion
by dental intrusion have been
reported by Orton et al. (1992);
however, the amount of gingival dis-
play was not assessed (Orton et al.
1992).
In cases of “gummy smile” asso-
ciated with hyperactive upper lip,
outcomes have been reported for
treatments with botulinum toxin
(Polo 2008) and myotomy (Ishida
et al. 2010). Polo (2008) treated 30
patients (29 females) for gummy
smile with botulinum toxin type A
and performed followed-up evalua-
tions at 2, 4, 8, 12, 16, 20 and
24 weeks post-injection. Although
Lip repositioning surgery 263
the baseline gingival display of
5.2  1.4 mm declined to 0.09 
1.06 mm at 2 weeks, a result consid-
ered highly favourable by specialty
clinicians, the effect of botulinum
toxin was transitory. Gingival dis-
gingival display during smile was
approximately 3 mm; the author
predicted a return to baseline values
2008); no other clinical parameters
were assessed in that study. Ishida
et al. (2010) described a combined
approach of myotomy of the Levator
Labii Superioris muscle, subperio-
steal dissection of the gingiva, subcu-
taneous dissection of the lip and
frenectomy for correction of gummy
baseline gingival display of
1.91  1.50 mm at 6 months; no
other clinical parameters or time
points were assessed in that study
(Ishida et al. 2010). The lack of
information on other parameters in
the botulinum toxin and myotomy
studies precludes any comparison of
the effects of the procedures on lip
and vermillion length. For the lip
repositioning surgery, changes in
gingival display correlated strongly
to the combined changes in lip and
vermillion length during smile.
It appears that the three treat-
ment modalities (botulinum toxin;
myotomy; modified lip repositioning
surgery) provide similar benefits in
terms of gingival display reduction,
at least at the early time points.
However, botulinum toxin injection,
which is the least invasive approach,
does not provide stable results and
requires frequent repeat treatments
to maintain the desired outcome.
Between the two surgical appro-
aches, myotomy is a much more
aggressive procedure with irrevers-
ible outcomes and greater potential
post-operative morbidity, such as
paresthesia (Miskinyar 1983). In
contrast, lip repositioning is a less
aggressive surgery whose outcomes,
if necessary, could be reversed by a
vestibular extension procedure. Fur-
thermore, lip repositioning surgery is
accompanied by limited morbidity,
with mucocele formation being the
most severe reported complication
(Rosenblatt & Simon 2006, Simon
et al. 2007).
264 Silva et al.
Thirty months after the procedure,
the overwhelming majority of patients
was highly satisfied with their smile
and would likely undergo the proce-
dure again. These results are unique
among studies where treatment of
excessive gingival display has been
evaluated. Patient-centred outcomes
were not included in the myotomy
procedure study (Ishida et al. 2010).
Polo (2008) assessed patient satisfac-
tion 2 weeks after botulinum toxin
injection; patients were very highly
satisfied with the smile improvement
and most of them would undergo the
procedure again. However, the tran-
sient nature of the botulinum toxin
outcome and the lack of subsequent
assessments of patient satisfaction pre-
clude any comparison with the present
results. The high level of satisfaction
with the modified lip repositioning
surgery suggests that the procedure
could enjoy widespread appeal among
populations other than the one investi-
gated in this study.
Despite its benefits and other
positive attributes, lip repositioning
surgery is not indicated in the pres-
ence of a narrow band of attached
gingiva, because of the ensuing diffi-
culty in flap design, suturing and sta-
bilization (Rosenblatt & Simon
2006, Simon et al. 2007). In addition
to the above technical difficulties,
narrow attached gingiva will inevita-
bly lead to a shallower and narrower
vestibule that could compromise the
patient’s ability to perform adequate
oral hygiene. Although lip reposi-
tioning is not indicated in cases of
severe vertical maxillary excess, it
has been suggested that it could be
of benefit in cases of mild maxillary
excess (Humayun et al. 2010); this
possible additional indication rem-
ains to be clinically investigated.
In conclusion, the presented modi-
fied lip repositioning surgery is a pre-
dictable technique for the treatment
of excessive gingival display due to
hyperactive upper lip, resulting in
high level of patient satisfaction.
Additional studies are necessary to
evaluate the long-term outcomes of
this procedure.
References
Ackerman, M. B. & Ackerman, J. L. (2002) Smile
analysis and design in the digital era. Journal
of Clinical Orthodontics 36, 221–236.
Armitage, G. C. (1999) Development of a classifi-
cation system for periodontal disease and con-
ditions. Annals of Periodontology 4, 1–6.
Borges, I. Jr., Ribas, T. R. & Duarte, P. M.
(2009) Guided esthetic crown lengthening: case
reports. General Dentistry 57, 666–671.
de Castro, M. V., Santos, N. C. & Ricardo, L. H.
(2006) Assessment of the “golden proportion”
in agreeable smiles. Quintessence International
37, 597–604.
Dong, J. K., Jin, T. H., Cho, H. W. & Oh, S. C.
(1999) The esthetics of the smile: a review of
some recent studies. International Journal of
Prosthodontics 12, 9–19.
Ezquerra, F., Berrazueta, M. J., Ruiz-Capillas, A.
& Arregui, J. S. (1999) New approach to the
gummy smile. Plastic and Reconstrutive Surgery
104, 1143–1150.
Flores-Mir, C., Silva, E., Barriga, M. I., Lagra-
vere, M. O. & Major, P. W. (2004) Layperson’s
perception of smile aesthetics in dental and
facial views. Journal of Orthodontics 31,
204–209.
Fradeani, M. (2006) Evaluation of dentolabial
parameters as part of a comprehensive esthetic
analysis. European Journal of Esthetic Dentistry
1, 62–69.
Garber, D. A. & Salama, M. A. (1996) The aes-
thetic smile: diagnosis and treatment. Periodon-
tol 2000, 11, 1, 8–28.
Geron, S. & Atalia, W. (2005) Influence of sex on
the perception of oral and smile esthetics with
different gingival display and incisal plane incli-
nation. Angle Orthodontist 75, 778–784.
Humayun, N., Kolhatkar, S., Souiyas, J. &
Bhola, M. (2010) 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. Journal of Periodontology 81,
1858–1863.
Ishida, L. H., Ishida, L. C., Ishida, J., Grynglas,
J., Alonso, N. & Ferreira, M. C. (2010) Myoto-
my of the levator labii superioris muscle and
lip repositioning: a combined approach for the
correction of gummy smile. Plastic and Recon-
strutive Surgery 126, 1014–1019.
Kokich, V. O., Kokich, V. G. & Kiyak, H. A.
(2006) Perceptions of dental professionals and
laypersons to altered dental esthetics: asymmet-
ric and symmetric situations. American Journal
of Orthodontics and Dentofacial Orthopedics
130, 141–151.
Litton, C. & Fournier, P. (1979) Simple surgical
correction of the gummy smile. Plastic and
Reconstrutive Surgery 63, 372–373.
Mazzuco, R. & Hexsel, D. (2010) Gummy smile
and botulinum toxin: a new approach based on
the gingival exposure area. Journal of the
American Academy of Dermatology 63,
1042–1051.
Miskinyar, S. A. (1983) A new method for cor-
recting a gummy smile. Plastic and Reconstru-
tive Surgery 72, 397–400.
Orton, H. S., Slattery, D. A. & Orton, S. (1992)
The treatment of severe ‘gummy’ Class II divi-
sion 1 malocclusion using the maxillary intru-
sion splint. European Journal of Orthodontics
14, 216–223.
Oumeish, O. Y. (2001) The cultural and philo-
sophical concepts of cosmetics in beauty and
art through the medical history of mankind.
Clinics in Dermatology 19, 375–386.
Paula, D. F. Jr., Silva, E. T., Campos, A. C.,
Nu~ nez, M. O. & Leles, C. R. (2011) Effect of
anterior teeth display during smiling on the
self-perceived impacts of malocclusion in ado-
lescents. The Angle Orthodontist 81, 540–545.
Peck, S., Peck, L. & Kataja, M. (1992) The gingi-
val smile line. The Angle Orthodontist 62,
91–100.
Pinho, S., Ciriaco, C., Faber, J. & Lenza, M. A.
(2007) Impact of dental asymmetries on the
perception of smile esthetics. American Journal
of Orthodontics and Dentofacial Orthopedics
132, 748–753.
Polo, M. (2005) Botulinum toxin type A in the
treatment of excessive gingival display. Ameri-
can Journal of Orthodontics and Dentofacial
Orthopedics 127, 214–218.
Polo, M. (2008) Botulinum toxin type A (Botox)
for the neuromuscular correction of excessive
gingival display on smiling (gummy smile).
American Journal of Orthodontics and Dentofa-
cial Orthopedics 133, 195–203.
Roden-Johnson, D., Gallerano, R. & English, J.
(2005) The effects of buccal corridor spaces
and arch form on smile esthetics. American
Journal of Orthodontics and Dentofacial Ortho-
pedics 127, 343–350.
Rosenblatt, A. & Simon, Z. (2006) Lip reposi-
tioning for reduction of excessive gingival dis-
play: a clinical report. International Journal of
Periodontics and Restorative Dentistry 26,
433–437.
Rubinstein, A. M. & Kostianovsky, A. S. (1973)
Cirugia estetica de la malformacion de la sonr-
isa. Prensa Medica Argentina 60, 952.
Silberberg, N., Goldstein, M. & Smidt, A. (2009)
Excessive gingival display–etiology, diagnosis,
and treatment modalities. Quintessence Interna-
tional 40, 809–818.
Simon, Z., Rosemblatt, A. & Dorfmann, W.
(2007) Eliminating a gummy smile with surgical
lip repositioning. Journal of Cosmetic Dentistry
23, 100–108.
Tjan, A. H., Miller, G. D. & The, J. G. (1984)
Some esthetic factors in a smile. The Journal of
Prosthetic Dentistry 51, 24–28.
Zahrani, A. A. (2010) Correction of vertical max-
illary excess by superior repositioning of the
maxilla. Saudi Medical Journal 31, 695–702.
Address:
Cl

everson O. Silva
Av. Colombo, 9727 – Km 130 – CEP:
87070-810
Maring
a – PR
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E-mail: prof.cleversonsilva@gmail.com
© 2012 John Wiley & Sons A/S

Clinical Relevance
Scientific rationale for the study:
Excessive gingival display is a com-
mon aesthetic concern for patients.
Certain cases of excessive gingival
display can be treated by lip repo-
sitioning surgery. The outcomes of
excessive gingival display treatment
by means of lip repositioning
© 2012 John Wiley & Sons A/S
surgery have not been previously
investigated.
Principal findings: In the absence of
any significant complications, and
with high level of patient satisfac-
tion, modified lip repositioning sur-
gery resulted in significant and
apparently stable reduction of gingi-
val display, which correlated
Lip repositioning surgery 265
strongly with the combined
increase of upper lip and vermillion
length.
Practical implications: Use of a
modified lip repositioning surgery
in indicated cases of excessive gin-
gival display can result in predict-
able and desirable outcomes with
minimal complications.