Laser-Assisted Lip Repositioning With Smile Elevator Muscle Containment and Crown Lengthening for Gummy Smile: A Case Report

Contemporary treatment techniques for excessive gingival display caused by altered passive eruption or lip hypermobility

OBJECTIVES

Excessive gingival display (EGD), also known as gummy smile, has various causes, including altered passive eruption (APE) and hypermobile upper lip (HUL). This state-of-the art narrative review explores current concepts regarding soft tissue EGD etiologies and the contemporary modalities available for APE or HUL treatment.

DATA, SOURCES, STUDY SELECTION

Literature search was conducted for a narrative review on the etiology, diagnosis, and treatment of EGD caused by APE and HUL. Searching for articles was carried out in PubMed and Google Scholar. Published articles, including case reports, case series, observational and interventional clinical trials, and critical appraisals of the literature (e.g., systematic reviews) on the etiology, diagnosis, and treatment of EGD caused by APE and HUL were retrieved and reviewed. Particular focus was placed on novel treatment modalities introduced in the last five years.

CONCLUSIONS

Recent research evidence indicates that APE and HUL are the two major soft tissue-based EGD etiologies. Aesthetic crown lengthening (ACL) and lip repositioning surgery (LRS) are the established surgical treatment modalities for APE and HUL, respectively. The last few years have seen the introduction of new techniques for APE and HUL management, an expansion of the available ACL and LRS technique variations, and additional evidence further supporting the effectiveness of these two procedures. Several of the recently introduced approaches offer unique, innovative, and potentially impactful concepts. However, for many of these newly described treatments the available evidence is limited to case reports and the exact indications remain to be adequately defined.

CLINICAL SIGNIFICANCE

Altered passive eruption and hypermobile upper lip are the common soft tissue causes of gummy smile and can be successfully managed through aesthetic crown lengthening and lip repositioning surgery, respectively. A wide range of newly introduced approaches promises to further facilitate gummy smile treatment and improve outcomes.

A Modified Approach in Lip Repositioning Surgery for Excessive Gingival Display to Minimize Post-Surgical Relapse: A Randomized Controlled Clinical Trial

Lip repositioning surgeries are performed to treat patients with excessive GD (EGD). This study aimed to explore and compare the long-term clinical results and stability following the modified lip repositioning surgical technique (MLRS) with the addition of periosteal sutures compared to the conventional lip repositioning surgery (LipStaT^®) in order to address EGD. A controlled clinical trial with female participants (n = 200) intended to improve their gummy smile were divided into control (n = 100) and test (n = 100) groups. The gingival display (GD), maxillary lip length at rest (MLLR), and maxillary lip length at maximum smile (MLLS) were measured at four time intervals (Baseline; 1 Month; 6 Months, and 1 Year) in millimeters (mm). Data were analyzed by t-tests, Bonferroni-test, and regression analysis using SPSS software. At the one-year follow-up, GD for the control and test groups were 3.77 + 1.76 mm and 2.48 + 0.86 mm, respectively, and their comparisons showed that GD was considerably lower (p = 0.000) in the test group compared to the control group. The MLLS measurements taken at baseline, one-month, six-month, and one-year follow-up showed no significant differences (p > 0.05) between the control and test groups. At baseline, one-month, and six-month follow-up, the mean and standard deviation for the MLLR were almost similar, with no statistically significant difference (p = 0.675). The MLRS is a successful and viable treatment option for the treatment of patients with EGD. The current study showed stable results and no recurrence with MLRS until the one-year follow-up compared to LipStaT^®. With the MLRS, a 2 to 3 mm decline in EGD is usually to be expected.

Lip Repositioning Techniques and Modifications

A common etiology of excessive gingival display is hypermobile upper lip, which can be managed by non-surgical and surgical approaches. Among the surgical options, lip repositioning surgery is a relatively simple procedure with minimal complications. Since the original description of the technique almost 50 years ago, several minor and major modifications have been introduced. The available evidence indicates that, when applied to properly diagnosed cases, the technique is effective in reducing gingival display and results in improved smile esthetics and high patient satisfaction. This article reviews the various techniques and modifications and summarizes the reported outcomes of the procedure.

Laser-Assisted Lip Repositioning Surgery: A Modification to The Conventional Technique

Introduction: The lip repositioning surgical technique arose with the objective of correcting and harmonizing the act of smiling. Since the conventional technique was published, some modifications of the technique have been proposed in order to counteract postoperative recurrence and to achieve the best esthetic appearance of the smile. The objective of this paper was to describe the laser-assisted lip repositioning technique (laser-assisted LRS) with a 940nm diode laser and 2780nm Er,Cr: YSGG, as a modification to the conventional lip repositioning technique, for the treatment of a gummy smile. Case Report: The proposed technique consists in achieving the descent of the upper lip by removing the intraoral mucosal band through the laser peeling of oral mucosa, preserving the connective tissue intact for healing by secondary intention. The technique was implemented in two patients with a diagnosis of a gummy smile caused by a short and hyperactive upper lip; the healing process was satisfactory, and there was no bleeding or postoperative edema. Postoperative controls were performed at 3 and 10 months, and no recurrence was found. Conclusion: the 940nm Diode laser or 2780nm Er,Cr: YSGG laser-assisted lip repositioning technique described here is less invasive than that performed with a conventional scalpel, offers aesthetic results, lower risk of infection and recurrence of the gummy smile in the long term.

Use of Diode Laser for Lip Repositioning, Evolution of the Conventional Technique. A Case Report

Introduction

LipStaT® lip repositioning surgery using a diode laser for the management of gummy smiles offers promising and consistent long-term results.

Objective

To describe the technique through a clinical case, including its indications, preoperative evaluation, surgical approach, and recommendations after the intervention.

Case Report

A 29-year-old woman with excessive gingival display (EGD) of 4 mm when smiling; the LipStaT® technique was performed with a 940 nm diode laser to remove a strip of mucosa by ablating the epithelial tissue, and thus, achieve aesthetic, harmonic and functional results. The inflammation and postoperative pain were treated with the diode laser assisted lymphatic drainage technique. After follow-up, a satisfactory tissue response was observed, and no pain or inflammation was reported.

Conclusion

The use of a 940 nm diode laser proved to be an effective treatment option for patients with a gummy smile, allowing control of intraoperative bleeding and improvement of the healing process obtaining predictable long-term results.

Gummy Smile Management Using Diode Laser Gingivectomy Versus Botulinum Toxin Injection - A Prospective Study

Introduction:

Gummy smile (GS) is a nonesthetic condition that affects the confidence of many young people. The present study aimed to compare the results of two approaches used in the management of GS in a group of Egyptian females.

Materials and Methods:

This comparative cohort study included 24 female patients aged 25–35 years, divided into two groups. Group A included patients treated with diode dental laser gingivectomy, while Group B included patients who were treated with Botox injection. The clinical assessment of the pre-and post-operative measurements of exposed gums in millimetres on an active full smile was analyzed and compared for both groups. The paired t-test was used to compare pre and post measurements in each group, and the mean difference between the groups was compared using the independent t-test.

Results:

Group A showed instant improvement, while Group B results appeared 1 week later. The variation between preoperative and postoperative GS measurements in both groups was statistically significant. The preoperative and postoperative mean ± standard deviation was (5.17 ± 0.9 and 1.89 ± 0.5) in Group A and (4.27 ± 1.0 and 1.79 ± 1.0) in Group B. Comparison between the two groups revealed a highly significant greater mean difference of 3.27 ± 0.5 mm in Group A than Group B (P < 0.001). The findings were satisfactory in all cases of both approaches, and there were no complications.

Discussion:

Using a diode laser to treat gummy smiles for oro-dental genetics case with gingival hypertrophy saves time and effort compared to conventional surgical techniques. Diode dental laser is a safe fast and effective method of treatment giving more superior results than Botox injection which showed a less invasive alternative temporary GS therapy that is easily guaranteed and more patient-favored.

An Innovative Procedure for Lip Lengthening in a Patient with a Short Upper Lip and High-Angle Skeletal Class II Pattern: A Case Report

Skeletal class II malocclusion in adult patients with severe gummy smile is challenging for orthodontist and often requires surgical intervention. The difficulty increases when patients refuse orthognathic surgery, and orthodontists have limited treatment alternatives. This report describes the case of a patient with severe dento-skeletal class II malocclusion with excessive gingival display while smiling. The patient was treated with temporary anchorage devices, and an innovative method of lip repositioning was devised to correct the irregularity.

Lip repositioning with or without myotomy: a systematic review

Excessive gingival display is an esthetic issue that is commonly managed by different procedures. Lip repositioning is a modality to address concerns of affected patients. The aim of this review was to investigate the scientific evidence on outcomes and long-term stability of lip repositioning surgery with or without myotomy. The electronic search was conducted in three databases: MEDLINE, Embase, and the Cochrane Library up to October 2019. No publication status, language, or time restrictions were applied. The electronic search was complemented by a manual search of the reference lists. Three hundred thirty-eight studies were screened by title, and 16 articles remained for data extraction. The included studies assessed the lip repositioning procedure in 144 patients aged between 15-59 years (134 females and 10 males). Based on the available data, lip repositioning with myotomy/muscle containment can be a successful treatment for minor discrepancies in gingival display in selected cases. However, further well-organized controlled clinical trials are recommended to derive a conclusion about the long-term stability compared with other alternatives.