CASE REPORT

Laser-Assisted Lip Repositioning With Smile Elevator Muscle Containment

and Crown Lengthening for Gummy Smile: A Case Report
Balaji Ganesh,∗ Nalina Kumari C. Burnice,∗ Jaideep Mahendra,∗ Rajaram Vijayalakshmi∗ and Anil Kumar K.∗

Introduction: Treating the patients with excessive gingival display to provide a pleasant smile is a challenge to the
periodontist. Gummy smile can be due to excessive vertical bone growth, dentoalveolar extrusion, short upper lip, upper
lip hyperactivity, or altered passive eruption. Gummy smile associated with hyperactivity of smile elevator muscles can be
treated by surgical techniques like lip repositioning, botulinum toxin injection, lip elongation with rhinoplasty, detachment
of the lip muscles, and myectomy. Regardless of the technique used, to achieve a predictable result with long-term stability
limiting upper lip movement when the patient smiles, firm muscle containment is imperative.
Case Presentation: The case report describes the excessive gingival display having a multifactorial etiology in a
25-year-old female patient. Altered passive eruption in upper anterior teeth was treated by crown lengthening followed by
management of hyperactive lip using a diode laser-assisted lip repositioning along with traction and muscle containment.
Excellent and predictable results were obtained after a 1-year follow-up without the relapse of gummy smile.
Conclusions: The case report showed an excellent result when treated by a combined approach of an innovative
procedure with laser-assisted lip repositioning aimed at maintaining the traction and containment of the smile elevator
muscles along with crown lengthening procedure by gingivectomy. Clin Adv Periodontics 2019;9:135–141.
Key Words: Gummy smile; lip repositioning; smile elevator muscles.

gingiva during a smile.2 The incidence of this condition

Background
One of the objectives of periodontal plastic surgery is
to create ideal esthetics for the patient’s smile. However,
some patients who present with gingival and skeletal
deformities may require more complex esthetic rehabili-
tation. For these challenging patients, a multidisciplinary
approach can be beneficial to enhance the balance and
harmony between all three components of the smile (the
teeth, lip framework, and the gingival scaffold).1 Excessive
gingival display (EGD), commonly called gummy smile, is
the term used when there is an overexposure of maxillary
∗ Department
of Periodontology, Meenakshi Ammal Dental College,
Chennai, Tamilnadu, India
Received September 19, 2018; accepted December 24, 2018
doi: 10.1002/cap.10060
is frequently associated with different etiologies such as
altered passive eruption (APE), anterior dentoalveolar
extrusion, vertical maxillary excess, and short and hyper-
active upper lip.3 To establish an appropriate treatment
plan, identifying the etiology of the EGD and an accurate
diagnosis are necessary.
Lip repositioning is a recommended treatment modal-
ity for patients with EGD associated with hypermobile
lip.4 The objective of lip repositioning is to shorten
the vestibule and limit the retraction of the lip eleva-
tor muscles by removing a strip of mucosa from the
maxillary buccal vestibule and attaching the lip mucosa
to the mucogingival line, thereby reducing the gingival
display at smiling.4 The appearance of the lip framework
is determined by the activity of various facial muscles,
such as the orbicularis oris (OO), levator labii superioris
(LLS), the levator labii superioris alaeque nasi (LLSAN),
and the zygomaticus minor (ZMi) muscles.5 This case
report describes a case of EGD treated by a combined

Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 135

C A S E R E P O R T

of gums while smiling. Extra-

oral clinical examination
revealed symmetric facial thirds
as well as a normal upper
lip length of 20 mm6 (Fig.
1). On intraoral examination,
periodontal tissues were found
to be healthy with an adequate
width of attached gingiva on the
facial aspect. High smile line and
7 mm of gingival display during
smile was detected (Fig. 2a).
Due to the aberration in the
normal steps of eruption termed
APE, 2 to 3 mm of the anterior
crowns were submerged by
excess gingiva, revealing short
clinical crown (disproportionate
crown height/ width ratio)
FIGURE 1 1a Preoperative smile (profile view). 1b Preoperative smile (frontal view). 1c Intraoral
view. (Figs. 2b and 2c) and squared
maxillary anterior teeth (Fig. 2).
Probing depth and clinical
attachment level were 3 mm in
relationship to upper anteriors
(teeth #6-#11) (Fig. 2d).
The preoperative radiograph
(orthopantomograph) was asse-
ssed (Fig. 3). During extrava-
gant smiling, an overexuberant
lip raising was observed, which
confirmed the presence of hype-
ractive upper lip. The patient
was diagnosed with EGD
associated with APE Type
1A according to the Coslet
classification7 and upper lip
elevator muscle hypermobility.
The treatment plan was
formulated as laser-assisted lip
repositioning with a modified
technique of the smile elevator
muscles containment along with
crown lengthening procedure
FIGURE 2 2a Seven-millimeter gingival display measured by UNC-15 probe. 2b and 2c Disproportionate
crown width and height. 2d Probing depth and clinical attachment level of 3 mm.
by laser gingivectomy.

approach of an innovative procedure with laser-assisted Case Management

lip repositioning aimed at maintaining the traction and
containment of the smile elevator muscles along with
crown lengthening procedure by laser gingivectomy.
Clinical Presentation
A 25-year-old woman with no significant medical history
reported to the Department of Periodontology, Meenakshi
Ammal Dental College and Hospital, Chennai, India, on
July 2017 with a chief complaint of excessive display
Before the surgical procedure, written informed consent
was obtained from the patient. As part of the routine
protocol, oral prophylaxis was done and oral hygiene
instructions were given. The surgical procedure was ini-
tiated after adequate infiltration local anesthesia (2%
lidocaine with 1:100,000 epinephrine) in relationship to
teeth (#6-#11).
Laser safety protocols were strictly followed. The
patient and the clinician were advised to put on
the laser safety glasses specific to the wavelength of the

136 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 Laser Lip Repositioning With Muscle Containment
 C A S E R E P O R T

was carried at an energy set-

ting of 1 W in a continu-
ous mode, using light brush
strokes to maintain the depth
of ablation, for removal of the
epithelial mucosa and expo-
sure of the underlying con-
nective tissue which was fol-
lowed by removal of tissue tags
and saline irrigation (Fig. 5).
Once the lip muscle bundle
fibers were identified on both
sides of the maxilla (Figs. 6
and 7), the suture containment
FIGURE 3 Orthopantomograph. of the smile elevator muscles,
namely the OO, LLS, LLSAN,
and ZMi was started using an
absorbable suture.‡ 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 (Figs. 8a and 9a). The
right-side muscle bundle fibers
from the LLS and LLSAN was
grasped at the height of the lat-
eral incisor and canine (in rela-
tionship to teeth #6 and #7)
and pulled downward, which
allows the fibers to be main-
tained close to their medial
and lateral bands before con-
tinuing the same procedure on
the left side (Figs. 8a and 9b).
Then, at the height of the
canine (in relationship to
tooth #11), the ZMi muscle
fibers from the left side were
FIGURE 4 4a Markings of the depth of gingival sulcus with Krane Kaplan pocket marker. 4b and 4c
Intraoperative view: laser-assisted crown lengthening by gingivectomy. 4d Postoperative view: laser-assisted properly grasped, holding
crown lengthening by gingivectomy. the same amount of tissue
with an adequate tension
laser. A 940 nm diode laser was used for the proce- (Figs. 8a and 9c). Consequently, after grasping the LLS,
dure.† The markings of the depth of gingival sulcus of LLSAN and ZMi muscle bundle fibers, the suture needle
upper anteriors was done with a krane Kaplan pocket was returned to the anchor starting point by grasping the
marker in relationship to teeth (#6-#11) (Fig. 4a). Then OO again (Figs. 8a and 9d), engaging all the suture threads
crown lengthening in relationship to teeth (#6-#11) was together with a surgeon’s knot (Figs. 8b and 9e). This
done by means of laser-assisted gingivectomy (Figs. 4b elevator muscle traction and suture containment helps to
through 4d). According to Coslet classification, APE was prevent the early muscle relapse in patients with EGD. The
Type 1A, hence no ostectomy/osteoplasty was performed. procedure was completed by approximating the midline
Following which laser-assisted lip repositioning was ini- tissues first, using 4-0 black silk with single interrupted
tiated, 400-µm laser tip in a continuous mode at 0.8 suture (external sutures) to ensure symmetry and proper
W was first used to demarcate the incision line. The lip midline placement with the midline of the teeth. The
first horizontal incision was outlined at the mucogingival remaining wound margins were approximated with inter-
junction and second horizontal incision at about 10 mm rupted sutures (Figs. 8c and 9f). Antibiotics (amoxicillin
parallel to the first incision. Both these outlines were 500 mg 8 hourly for 5 days) and analgesics (aceclofenac
connected at the distal end of the canines. Laser ablation + paracetamol, 12 hourly for 3 days) were prescribed.

† Dentsply Sirona 940 nm ‡ Ethicon, Johnson & Johnson Private Limited, India

Ganesh, Burnice, Mahendra, Vijayalakshmi, Kumar Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 137
C A S E R E P O R T
FIGURE 5 5a Lip repositioning—incision line demarcated with the fiber optic laser tip—first horizontal incision expectations of patients with
placed at mucogingival junction. 5b Second horizontal incision placed about 10 mm apical of the mucogingival
junction. 5c Epithelium removed and connective tissue exposed. 5d The strip of epithelium was removed.
FIGURE 6 Insertion of smile elevator muscles.
Use of 0.12% chlorhexidine rinse was also advised. The
patient was instructed to apply an ice pack, avoid any
mechanical trauma in the surgical site, and minimize
lip movement when smiling and talking for 2 weeks.
Clinical Outcome
External sutures were removed 2 weeks postoperatively
(Fig. 10). The patient reported mild pain and tension while
smiling or talking in the first week. A minor scar was
formed on the suture line but remained invisible during
smiling. No postoperative swelling was seen extraorally
in facial and infraorbital areas.
Patient was reviewed after 6 months (Fig. 11) and
12 months postoperatively (Fig. 12). No prosthetic
138 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019
treatment was done as ade-
quate crown height and width
was achieved by gingivectomy
and patient’s esthetic require-
ments were met. The post-
operative probing depth,
clinical attachment level, and
gingival display was 2, 2, and
3 mm, respectively, and it was
maintained at 6 and 12-month
follow-up (Table 1). The
patient was highly satisfied
with the treatment outcome
(Fig. 13).
Discussion
Esthetic dental treatments have
now become relatively com-
mon, and this has increased the
regard to achieving a harmo-
nious smile. Such harmony can
only be achieved if there is due attention paid to the
esthetic proportionality between the teeth and gums. Lips
define the esthetic zone and the lip line can be defined,
while smiling as low, medium, or high.8 The lip line is
considered low when only part of the teeth are visible
below the upper lip, medium when 1 to 3 mm of the
marginal gingiva is exposed during a smile and high
(gummy smile) when >3 mm of gingiva is exposed.8
Hypermobility of the maxillary lip can be managed
by lip-repositioning surgery. Lip repositioning was first
reported as a corrective method for a gummy smile in
1973 by Rubenstein and Kostianovsky.9 Another aggres-
sive approach for treating EGD includes myectomy and
partial resection of the LLS.10 Lip elevation on smiling can
also be limited by placing a silicon spacer between elevator
muscles of the lip and the anterior nasal spine.11 Later,
an elliptical-shaped incision at the mucogingival junction
and the alveolar mucosa, reflecting a partial thickness
flap and removing a strip of the mucosa was proposed
for lip repositioning.4 A combined approach for treating
EGD included myotomy of the LLS muscle, subperiosteal
dissection of the gingiva, subcutaneous dissection of the
lip, and frenectomy.12 One of the disadvantages of this
technique is the increased potential for postoperative mor-
bidity and paresthesia due to the aggressive dissection
around the infraorbital nerve.12
In the present case report, the patient had EGD caused
by APE Type 1A associated with upper lip elevator mus-
cle hypermobility with a gingival display of 7 mm in
a dynamic smile. The combination of a lip reposition-
ing technique with the traction and containment of the
smile elevator muscles namely OO, LLS, LLSAN and ZMi
was described by Saba Chujfi,13 where he obtained a
pleasant and stable result to be achieved within a 1-year
follow-up without lip relapse to its original position or
Laser Lip Repositioning With Muscle Containment
 C A S E R E P O R T

containment sutures. The

internal sutures allow 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. The
primary advantages of laser
application in soft tissue
surgery are relatively bloodless
surgery with coagula-
tion and reduced bacteremia
with minimal discomfort
postoperatively.14 Bleeding
associated with conventional
lip repositioning procedures
results in hematoma
postoperatively, complicating
the healing process. This
FIGURE 7 Identification of muscle fibers. 7a Insertion of orbicularis oris. 7b Insertion of zygomaticus minor.
7c Insertion of levator labii superioris and levator labii superioris alaeque nasi. serves as a reservoir for
bacteria and tends to
loosen the sutures in the
initial healing period. Laser-
assisted excision serves as an
alternate option and provides
immediate hemostasis thereby
reducing the incidence of
hematoma.14 Furthermore,
a bloodless surgical field
enhanced relative ease of
suturing which is pivotal to
the success of the procedure.
The advantages of this tech-
nique are limited retraction
of the smile elevator muscles,
thus helping to achieve a long-
term stability (of >1 year) as
reported in the literature.13,15
The suture containment done
in the present case report min-
imized the risk of postopera-
FIGURE 8 8a Suture containment technique. 1: First suture bite taken in relationship to OO muscle at midline. tive lip relapse toward its orig-
2: Second suture bite taken in relationship to right side muscle bundle fibers from the LLS and LLSAN (teeth
#6, #7). 3: Third suture bite taken in relationship to left side muscle bundle fibers from the ZMi (tooth #11). 4:
inal position, and esthetically
The suture needle was returned to the anchor starting point by grasping the OO again, engaging all the suture pleasant results, better than the
threads together with a surgeon’s knot. 8b Final tightening of the knot done in suture containment technique. conventional technique, were
8c Single interrupted suture placement (external sutures).
achieved. A major benefit of
the laser use in our case report
further postoperative complication such as the formation was less bleeding intraoperatively and relatively less
of mucocele, paresthesia, or transient paralysis as reported discomfort in the postoperative period. An added
in the literature.4 advantage with the laser was high patient acceptability
The technique in this case report is modified by of the procedure due to its ease and less morbidity.
containment of smile elevator muscles along with use Contraindications for this technique includes severe
of diode laser for treating EGD. Proper knowledge of vertical maxillary excess (>8 mm), the presence of a
the anatomy, location, and insertion of the lip elevator minimal zone of the attached gingiva, which can create
muscles is necessary, for placing appropriate bilateral difficulties in flap design, stabilization, and suturing.

Ganesh, Burnice, Mahendra, Vijayalakshmi, Kumar Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 139
C A S E R E P O R T

FIGURE 9 Suture containment (internal sutures). 9a Muscle bundle fibers from the orbicularis oris initially grasped with vicryl 5.0
(Ethicon). 9b Right muscle bundle fibers from the levator labii superioris and levator labii superioris alaeque nasi grasped at the height
of the lateral incisor and canine (in relationship to teeth #6, #7). 9c Left muscle bundle fibers from the zygomaticus minor grasped
(in relationship to tooth #11). 9d Suture needle returned back to the anchored point at the orbicularis oris muscle bundle. 9e Final
tightening of all the suture threads from both sides of the surgical area at the middle point of the anchored knot. 9f 4-0 black silk
interrupted sutures to stabilize the line of closure (external sutures).

FIGURE 12 Postoperative smile (1 year).

FIGURE 10 Postoperative smile (2 weeks).

FIGURE 11 Postoperative smile (6 months).

TABLE 1 Clinical parameters at baseline and 12 months

after surgery

Clinical parameters Baseline 12 months

Probing depth 3 mm 2 mm
Clinical attachment level 3 mm 2 mm
Gingival display 7 mm 3 mm
FIGURE 13 Comparison of preoperative smile and 1-year
postoperative smile.

140 Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 Laser Lip Repositioning With Muscle Containment
 C A S E R E P O R T

Follow-up at 6 months and 1 year showed stable results
and the patient was satisfied with the treatment outcomes.
Conclusions
Laser-assisted lip repositioning technique with the trac-
tion and containment of the lip elevator muscles using a
sling suture along with esthetic crown lengthening is an
effective procedure for reducing EGD caused by upper
lip elevator muscle hypermobility and APE Type 1A. We
achieved a good esthetic outcome with reliable stabil-
ity at the 1-year follow-up. Considering the ease of the
procedure, excellent patient acceptability, and providing
satisfactory treatment outcome, this can be considered
as a novel feasible alternative in esthetic correction of
gummy smile.

Summary
Why is this case new  To our knowledge, the present case report is the first technique in the
information? literature for the treatment of gummy smile with a novel laser-assisted
lip repositioning with suture containment.

What are the keys to successful
management of this case?
 Containment with sutures allows the stabilization of the muscle bundle
on both sides of the surgical area, which prevents early relapse of
gummy smile.
 Use of a diode laser, which aided in better esthetic results and
enhanced patient compliance.

What are the primary limitations  Detailed knowledge about the anatomy of lip musculature is required to
to success in this case? perform the suture containment technique.

Acknowledgment 6. Sabri R. The eight components of a balanced smile. J Clin Orthod

The authors report no conflicts of interest related to this
case report.
CORRESPONDENCE
Dr. Jaideep Mahendra, MDS, PhD, Post Doc (USA), Director of
Post Graduate Studies; Professor, Department of Periodontics,
Meenakshi Ammal Dental College, Alapakkam Road, Maduravoyal,
Chennai 600095, Tamilnadu. Email: jaideep_m_23@yahoo.co.in;
jaideep_perio@madch.edu.in
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Ganesh, Burnice, Mahendra, Vijayalakshmi, Kumar Clinical Advances in Periodontics, Vol. 9, No. 3, September 2019 141