Clinical efficacy of lip repositioning technique and its modifications for the treatment of gummy smile: systematic review and meta-analysis

Clinical and radiographic assessment of gummy smile patients with altered passive eruption: a cross-sectional study in a Thai population

OBJECTIVES

The study aimed to evaluate the clinical crown length (CCL) among patients diagnosed with altered passive eruption (APE), the causes of a gummy smile, the prevalence of APE, and the correlation between parameters.

MATERIALS AND METHODS

A total of 86 gummy smile patients (516 teeth) underwent clinical examination and assessment using cone-beam computed tomography (CBCT), photography, and intraoral scanning.

RESULTS

Significantly shorter CCL and distance between the cementoenamel junction and bone crest (CEJ-BC) were observed among APE-affected teeth (p < 0.05). Among the patients, 56.1% of patients were diagnosed with APE, and most of them were affected by a combination of APE and hypermobile upper lip (HUL). Based on 183 APE-affected teeth, the prevalence of APE types and subtypes was as follows: APE1A (96; 19.3%), APE1B (78; 15.9%), APE2A (8; 1.6%), and APE2B (1; 0.2%). Positive correlations were found between keratinized gingival width (KGW) and bone thickness (BT), while negative correlations were observed between gingival thickness (GT) and BT.

CONCLUSION

Shorter CCL and CEJ-BC were the highlighted features of APE. APE affected approximately half of the gummy smile patients, with most of them presenting with a combination of HUL. Almost teeth affected by APE were classified as Type I, with a nearly equal distribution between subtypes A and B.

CLINICAL RELEVANCE

The clinical and radiographic features of APE contribute to a better understanding of this condition and facilitate the management of patients affected by APE. Approximately half of gummy smile patients will require multidisciplinary treatment.

Neurotoxins and Combination Therapies

BACKGROUND

Facial aging involves multilevel changes, extending from the skin to deep support structures. A comprehensive treatment approach targeting the many aspects of facial dynamics and architecture is often necessary to achieve optimal correction, prevent changes before they occur, and/or help highlight inherited features.

OBJECTIVE

To explore the integration of botulinum toxin type A (BoNT-A) into multimodal aesthetic treatment plans.

MATERIALS AND METHODS

This article reviews evidence supporting the combination of BoNT-A with other minimally invasive cosmetic therapies, including dermal fillers, lasers, and energy-based devices as well as with plastic and reconstructive surgeries for more controlled healing and improved scar cosmesis.

RESULTS

Combination treatment protocols including BoNT-A demonstrate higher patient satisfaction and retention rates compared to monotherapy or sequential treatments. Some guidelines for sequencing of treatments exist, but evidence is scant with certain combinations.

CONCLUSION

Integrating BoNT-A into a larger aesthetic treatment plan is crucial for achieving natural and satisfying results in facial rejuvenation. Evidence supports better outcomes when incorporating with both surgical and nonsurgical modalities. Understanding how to address anatomy over time through different aesthetic therapies together allows for individually tailored, more deeply impactful treatment plans.

A Systematic Review and Meta-Analysis Comparing Surgical and Nonsurgical Treatments for Excessive Gingival Display

Excessive gingival display (EGD) is defined as more than 2 mm of gingiva display above the maxillary incisors at maximum smile. Various skeletal, dental, and soft tissue etiological factors for EGD have been suggested. This study assessed the effectiveness and stability of surgical (SX) and nonsurgical (NSX) interventions for correction of EGD through a systematic review and meta-analysis following PRISMA 2020 guidelines. An electronic search of Ovid MEDLINE, EMBASE, CENTRAL, Scopus, Web of Science, and LILACS was conducted (2010-2023). Results were expressed as mean change in gingival display using the random-effects model at 1, 3, 6, and 12-month follow-up. At 1 month, SX and NSX treatments yielded a comparable mean reduction of 3.50 mm (2.13-4.86) and 3.43 mm (2.67-4.19) in gingival display, respectively. However, by 6 months, NSX treatments showed a reduction of 0.51 mm compared to 2.86 mm with SX treatments. SX outcomes remained stable past 6 months, while NSX outcomes partially relapsed at 6 months and returned to baseline levels at 12 months. Notably, NSX treatments were more effective in cases with mild initial EGD, while SX treatments showed a better outcome in severe cases. To draw more robust conclusions regarding the treatment outcomes, future primary studies of greater rigor are required.

Lip Repositioning Surgery: A Simple Smile and Life Transformation Procedure

Excessive display of the gums when smiling, known as gummy smiles, can lead to aesthetic concerns and emotional discomfort for individuals. In recent times, there has been a notable rise in the popularity of gummy smile surgery as a cosmetic procedure aimed at addressing this problem. A novel technique known as lip repositioning has emerged and gained recent popularity, either on its own or in conjunction with other approaches. In specific situations, it offers a simpler, less intricate alternative to more extensive surgical procedures, resulting in a pleasing and satisfactory camouflage effect while reducing postoperative complications. This case report illustrates the effective treatment of a gummy smile in a patient with excessive gum exposure using a lip repositioning technique. The procedure involved the removal of a partial thickness strip of mucosa lining in the maxillary buccal vestibule, without including the labial frenulum, and suturing the lip lining to the gum line. Our aim was to present lip repositioning as an effective method for reducing excessive gum exposure and addressing any unevenness in a minimally invasive manner. We sought a solution that offers long-lasting results over time while minimizing the chances of the issue recurring, with a 14-month follow-up.

Modified Lip Repositioning Surgery with and without Dual-layered Suturing for Treatment of Gummy Smile Patients

Background

The present study was performed to evaluate the differences in the efficacy of treating excessive gingival display with the standard modified lip repositioning surgery or the modified lip repositioning surgery with dual-layered suturing.

Methods

This study included 20 female patients who had a gummy smile resulting from upper lip hypermobility or short upper lip. Preoperative measurements of the amount of gum exposure were taken during involuntary smiling. The patients were randomly divided into two groups; the first group was treated with the standard technique, whereas the second group was treated with the double-layered suturing method. All patients were followed up at 14 days, 3 months, and 6 months; postoperative assessment was done by measuring the changes in the gingival display during spontaneous smiling.

Results

Postoperative measurements at 14 days follow-up showed a significant reduction in the amount of gingival exposure in both groups. However, at 3 months, there was a complete relapse for the first group of patients, whereas the second group showed a slight regain in the amount of gum exposure, though the latter group showed a complete relapse at 6 months postoperative.

Conclusions

The dual-layered suturing for the modified lip repositioning surgery did not provide any long-term improvement for treating gummy smile patients; however, it did delay the relapse to a certain extent for the first 3 months postoperative in some of the patients.

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.

Digital Smile Makeover: A Multidisciplinary Team Approach

Aesthetics is a fundamental part of contemporary dental practice. A pleasant smile depends on the gingival tissue architecture and dental characteristics. Excessive gingival display (gummy smile) is considered an unattractive smile and can affect a person's confidence. There are many etiological factors related to a gummy smile. Aesthetic rehabilitation of these cases often requires an interdisciplinary approach and close collaboration between dental specialties. This article describes an approach to excessive gingival display management caused by short teeth and hyperactive lips using a digital workflow for crown lengthening. A digital approach enables predictable planning and decreases the need for postsurgical modifications, thus shortening the treatment duration. Computer software is used for planning and 3D-printed guide for crown lengthening and implant placement. Two months later, lip repositioning was performed to reduce the hyperactive lip. After 4 months, prosthetic treatment and Botox injections were done to restore an aesthetic smile.

Botulinum Toxins and Lip Repositioning Surgery with Repeated Botulinum Toxin Injection: A Combined Approach for Gummy Smile Treatment

This study was conducted to evaluate the longevity and efficacy of neurotoxin injection before lip repositioning surgery in addition to reinjection of two sustaining doses along three different postoperative intervals (2, 4, and 8 months). This experimental study included 10 female patients who had a gummy smile resulting from upper lip hypermobility or short upper lip. Preoperative measurements were taken during spontaneous smiling: the interlabial distance and the amount of gingival exposure. IncoBotulinum Toxin A was injected into the elevator muscles of the upper lip followed by performing the lip repositioning surgery after 2 weeks of IncoBotulinum Toxin A injection. IncoBotulinum Toxin A was then reinjected at three different postoperative intervals (2, 4, and 8 months). All patients were followed up at 14 days, 4 months, 8 months, and 12 months. Postoperative measurements at 14 days follow-up showed a significant reduction in the amount of gum exposure and in the interlabial distance during smiling. Both changes remained stable up to 1 year, despite the minimal relapse that was observed; all the patients reported a high degree of satisfaction. Combining neurotoxins before and after the lip repositioning surgery may provide long-lasting results up to 1 year and better stability for the success rate of the surgery, where the use of each approach alone (IncoBotulinum Toxin A alone/surgery alone) may offer a temporary improvement.

Treatment of gummy smile combining crown lengthening, lip repositioning, and the use of polyester threads

INTRODUCTION

The case report presents a new possibility of treatment for a gummy smile in a patient with multiple etiologies, such as altered passive eruption and hypermobility upper lip. At first, crown lengthening was not sufficient to achieve the desired aesthetic result, being necessary its combination with lip repositioning.

CASE PRESENTATION

Crown lengthening surgery (CLS) was performed in a 20-year-old woman, with a gingival display of 7.5 mm, having her gingival exposure reduced to 5.5 mm. Because the patient continued unsatisfied after 6 months, a new procedure was adopted. To reduce even more her gingival exposure, lip repositioning technique was performed associated with myotomy and the insertion of polyester threads as a physical barrier to prevent relapse.

CONCLUSION

The result of the gingival display was reduced to 2.5 mm, removing the condition of a gummy smile after the combination of both techniques: crown lengthening, and lip repositioning.

KEY POINTS

Why is this case new information? Association of the technique of lip repositioning and myotomy, the insertion of polyester threads that act as a physical barrier against recurrence. What are the keys to successful management of this case? Correct etiological diagnosis. Prior application of botulinum toxin. Respect the period of 1 month for the insertion of the polyester thread, helping to preserve the suture (limitation of movement). What are the primary limitations to success in this case? Make the patient aware not to move the lips with the hands in order to observe the incision.

A Lip Repositioning Technique Using Polyester Threads for Gummy Smile Treatment

A new technique is proposed in this study to correct the gummy smile (GS) with myotomy, combining lip repositioning with the insertion of polyester threads at the surgical site to act as a physical barrier and control relapse. 11 patients were clinically assessed (30.2 ± 7.43 years old, 90.9% females and 9.10% males). All patients presented gingival display (GD) greater than 4 mm. Hypermobile upper lip (HUL), vertical maxillary excess (VME) + HUL, altered passive eruption (APE) + HUL, and VME + APE were the etiologies identified. Three polyester threads were inserted in each patient one month after the surgery. The GS was measured before, 6 months, and 12 months after the surgery. The results showed a reduction in the mean GD of the patients, 4.42 mm after 6 months (p value = 0.000) and 4.13 mm after 12 months (p value = 0.000). The largest relapse was 0.29 mm and was not statistically significant (p value = 0.07). The Friedman test with pairwise comparisons was used to determine the existence of statistically significant differences in GD between the periods analyzed. The results showed that the proposed technique was successful in treating GS, presenting significant reductions in the GD 12 months after surgery and controlling the relapse.