Labial repositioning using polymethylmethracylate (PMMA)-based cement for esthetic smile rehabilitation-A case report

A Smile Reimagined: Gummy Smile Resolution with Cutting Edge Method Using Chu's Gauge and Polymethylmethacrylate (PMMA) Bone Cement

Excessive gingival display (EGD) is one of the most common aesthetic concerns, and its correction often presents a challenge to periodontists. It has a multifactorial etiology, and this article describes a case involving hypermobile upper lip (HUL), altered passive eruption (APE), and vertical maxillary excess (VME). Upon investigation, a positive collum angle and marked subnasal skeletal depression were observed. In this context, it is noted that during a spontaneous smile, the upper lip retracts and gets lodged in this depression. The rehabilitation plan includes included aesthetic crown lengthening via gingivectomy using Chu's proportional gauge for altered passive eruption and filling the subnasal depression by PMMA (polymethylmethacrylate) bone cement. The entire treatment plan was digitalised using cutting edge methods such as computed tomography (CT), cone beam computed tomography (CBCT), and 3D printers for virtual planning of the defect's position, size, and shape. No postoperative complications were reported. After six months, the patient exhibited a harmonious smile with reduced exposed gingiva.

Effects of polymethyl methacrylate-based bone cement graft for treating excessive gingival display and its dimensional facial changes: 12-Month clinical study

Objective

to present a 12-month follow-up with photographic and tomographic analyses of the effect of polymethyl methacrylate-based bone cement graft (PMMA) in gingival exposure (GE) in patients with excessive gingival display (EGD).

Methods

Twelve patients with EGD were included. The PMMA was surgically placed. A frontal and lateral photograph protocol was performed at baseline (T0), 3 (T3), 6 (T6), and 12 months (T12) post-operatively. Soft tissue cone-beam computed tomography (ST-CBCT) was performed at T0 and T12. Measures included GE, length of the lip vermilion (LLV), lip shape (LS), nose width (NW), filter width (FW), nasolabial angle (NAS) while smiling, and nasolabial angle at rest (NAR). The height, thickness, and volume of the cement graft were also measured in the ST-CBCT. The comparisons were performed by Kruskal-Wallis test at 5 % of significance (p < 0.05).

Results

The height, thickness, and volume of the PMMA were respectively 12.84 ± 1.59 mm, 3.83 ± 0.53, and 1532.02 ± 532.52 mm3. PMMA significantly decreased GE from 8.33 ± 1.25 mm (T0) to 6.60 ± 0.93 mm (T12) (p < 0.01). NAR was 98.34 ± 9.28° at T0 and increased to 105.13 ± 7.33° at T12; however, the angle value was not statistically different (p = 0.08). LLV, LS, NW, FW, and NAS did not exhibit statistical differences between the baseline and follow-up periods.

Conclusions

PMMA significantly decreased GE in a 12-month follow-up without influencing adjacent soft tissue anatomical structures.

Accuracy of three types of digital guides for crown lengthening surgery: An in vitro study

Background/purpose

The guided protocols always yield a higher accuracy than freehand surgery. However, the accuracy of digital guides for crown lengthening surgery (CLS) is unknown. The purpose of this study was to evaluate the trueness of 3 types of digital guides for CLS.

Materials and methods

Twenty individually designed maxillary models were divided into 4 groups according to surgical guides: type I (T1), type II (T2), type III (T3), and free-hand. T1 comprised a planed gingival margin at the tissue level. T2 included both the planed gingival margin and alveolar crest at the tissue level. T3 consisted of a planed gingival margin at the tissue level and an alveolar crest at the bone level. CLS was performed under the indication of the guides. Trueness of the guides was evaluated through the deviation of the gingival zenith and alveolar crest height.

Results

The control group had higher vertical and horizontal distance deviations of gingival zenith compared to the 3 digital guide groups (P < 0.001). There were no significant differences among the 3 test groups in terms of gingival zenith deviations (P > 0.05). With regard to height deviation of alveolar crest, the control and T1 groups were higher than T2 group (P < 0.001), while T3 group had the lowest deviations among the 4 groups (P < 0.001).

Conclusion

The digital guides assisted CLS procedures are more accurate than free-hand method. The trueness of type III guide was better than type I and type II.

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.

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.

Labial Repositioning Using Print Manufactured Polymethylmethacrylate- (PMMA-) Based Cement for Gummy Smile

Treating patients with excessive gingival display (EGD) to provide them with a pleasant smile is a challenge to periodontists. A gummy smile can be due to excessive vertical bone growth, dentoalveolar extrusion, short upper lip, upper lip hyperactivity, or altered passive eruption (APE). In addition, many patients have a lack of lip support due to marked depression of the anterior process of the maxilla. In these cases, lip repositioning using polymethylmethacrylate (PMMA) cement could be performed. This article describes a case of EGD with subnasal depression. In the clinical examination, the presence of a marked subnasal depression was found, in which the upper lip lodged during a spontaneous smile. In addition to this, gingival exposure extending from the maxillary molar on one side of the mouth to the one on the opposite side was also found during the spontaneous smile. Therefore, the periodontal surgical intervention proposed consisted of performing a procedure to fill the subnasal depression with PMMA cement. This article describes a digital approach to plan the use of PMMA cement in lip repositioning in a patient with gummy smile and subnasal depression. The patient reported no postoperative complications. Six months after the surgery, the patient revealed a more harmonious smile than before, with reduction in the gingival exposure and new adequate support for and repositioning of the upper lip.

Facial trauma reconstruction with polymethyl methacrylate-A case report

BACKGROUND

Polymethyl methacrylate (PMMA) is a dermatologic filler commonly used in esthetic procedures. However, it can also be used in more severe cases such as reconstruction of facial traumas.

AIMS

The aim of this report was to describe the use of PMMA in a nasal reconstruction of a patient victim of an automobilist accident which presented previous rejection of autograft.

PATIENT

A young female patient, 26 y, victim of automobilist accident, with no bone support due to trauma both in the mandibulum and maxilla, presented fracture of several facial bones. Presented rejection of a bone autograft from the skullcap implanted on the nose. In order to harmonize the facial aspect, a nasal fill with PMMA for the anatomic reconstruction of the nose was performed.

RESULTS AND CONCLUSIONS

PMMA promoted the recovery of facial and nasal esthetic characteristics of the patient ensuring a satisfactory result.