Clinical Science Simon, Rosenblatt, Dorfman

Eliminating a Gummy Smile with Surgical Lip Repositioning

by Ziv Simon, D.M.D., M.Sc., Ari Rosenblatt, D.D.S., D.M.D., William Dorfman, D.D.S., F.A.A.C.D.

Dr. Simon is a periodontist who completed his specialty training and obtained his Master of Science degree at the University of Toronto. He is a Diplomate of the American Academy of Periodontology as well as a Fellow of the Royal College of Dentists of Canada. He maintains a practice limited to periodontics, dental implants, and reconstructive surgery in Beverly Hills, California; and taught as a clinical assistant professor at the University of Southern California. Dr. Simon lectures nationally as well as internationally and was featured on ABC’s Extreme Makeover.

Dr. Rosenblatt is a periodontist who completed his specialty training at Tufts University. He has served on the dental school faculties of Tufts University, UCLA, and the University of Southern California. He is a member of the American Academy of Periodontology, the American Academy of Oral Medicine, the American Dental Association, the Academy of Osseointegration, and the Beverly Hills Academy. Dr. Rosenblatt maintains a practice limited to periodontics, dental implants, and reconstructive surgery in Beverly Hills. Dr. Rosenblatt was the featured periodontist on ABC’s Extreme Makeover.

Dr. Dorfman is a 1983 graduate of University of the Pacific Dental School and has been practicing cosmetic dentistry for more than 23 years in the Beverly Hills area. He is the founder of Discus Dental and publishes and lectures worldwide. As the featured dentist on ABC’s Extreme Makeover, he has helped bring cosmetic dentistry to international recognition. He has recently appeared on numerous other television programs and is the author of the New York Times best seller Billion Dollar Smile. Dr. Dorfman is the recipient of five lifetime achievement awards from some of dentistry’s most noted organizations.

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Figure 1: Preoperative smile showing delayed Figure 2: Postoperative smile after an esthetic crown eruption, caries, and tetracycline discoloration. lengthening and restorative treatment. Dentistry, University of Southern California (USC) School of Dentistry.

Abstract Introduction rassment. In the so-called “gummy Excessive gingival display, com- One objective of restorative den- smile,” the gingivae are the domi- monly referred to as a “gummy tistry is to create ideal esthetics for nant feature when compared to the smile,” can be a source of embar- the patient’s smile. Advances in den- lips and teeth. At least 50% of pa- rassment for some patients. Delayed tal materials and laboratory tech- tients exhibit some form of gingival 1 eruption and tooth malpositioning niques have led to excellent mimicry display in a normal smile . However, can be predictably treated with resec- of the natural dentition with crowns, exaggerated or forced smile patterns tive surgery and orthodontics. In pa- veneers, and composite restorations. in up to 76% of all patients may ex- tients with jaw deformities, orthog- However, some patients who pres- hibit gingivae. In absolute numbers, nathic surgery can be performed, ent with gingival and skeletal defor- a normal gingival display between but this requires hospitalization mities may require more complex the inferior border of the upper lip and entails significant discomfort. esthetic rehabilitation. For these and the gingival margin of the an- The case presented here describes a challenging patients, a multidisci- terior central incisors during a “nor- 2 surgical technique for lip reposition- plinary approach can be beneficial mal” smile is 1-2 mm. In contrast, ing to reduce gingival display. The to enhance the balance and harmo- an excessive gingivae-to-lip distance procedure restricts the muscle pull ny between all three components of of 4 mm or more is classified as “un- of the elevator lip muscles by short- the smile: lips, teeth, and gingivae. attractive” by lay people and general 3 ening the vestibule, thus reducing dentists. the gingival display when smiling. An excessive gingivae-to-lip Four etiologies In our experience this procedure is distance of 4 mm or more is Excessive gingival display has safe, predictable with minimal risk classified as “unattractive” by lay four possible etiologies. First, it may or side effects, and is an alternative people and general dentists. be a result of delayed eruption in treatment modality in esthetic treat- which the gingivae fail to complete ment. the apical migration over the maxil- Excessive gingival display can lary teeth to a position that is 1 mm be a major cause of patient embar-

Volume 23 • Number 1 Spring 2007 • The Journal of Cosmetic Dentistry 103 Clinical Science Simon, Rosenblatt, Dorfman

Figure 3: Excessive gingival display due to attrition Figure 4: Retracted view, demonstrating signs of and compensatory eruption. attrition and compensatory eruption.

Figure 5: Rest position of a patient with vertical Figure 6: Smile view of a patient with vertical maxillary excess demonstrating incompetent lips. maxillary excess. Dentistry, University of Southern California (USC) School of Dentistry. Dentistry, University of Southern California (USC) School of Dentistry.

Figure 7: Preoperative smile with excessive gingival Figure 8: Postoperative smile after three months. display.

104 The Journal of Cosmetic Dentistry • Spring 2007 Volume 23 • Number 1 Clinical Science Simon, Rosenblatt, Dorfman

coronal to the cement-enamel junc- recently published in the dental lit- chief complaint and informed con- tions.4,5 In these patients, restoring erature.11 sent for a lip repositioning proce- the normal dentogingival relation- During patient examination, it is dure was obtained. ships can be achieved with an es- important to establish the etiology Under local anesthetic, three car- thetic crown lengthening, which is a responsible for the excessive gingi- pules of Lidocaine (Lidocaine HCl well-documented treatment modal- val display. A diagnosis of delayed 2%, 1:100,000 epinephrine) and ity that is highly effective in treating eruption, tooth malpositioning, and two carpules of Marcaine (Bupiva- 6,7 patients with delayed eruption. excessive skeletal deformities might caine HCl, 1:200,000 epinephrine), The procedure involves moving the best be treated by crown lengthen- the lip repositioning procedure was gingival margins apically through ing, orthodontics, and/or orthog- performed and is described in the soft and possibly hard tissue resec- nathic surgery. Lip repositioning next section. tion (Figs 1 & 2). is suggested as an additional treat- Immediately after surgery, the The second possible cause is com- ment modality for patients with lip patient reported “tightness” on her pensatory eruption of the maxillary hypermobility exposing undesired upper lip when she smiled and mild teeth with concomitant coronal mi- gingivae in a smile. The objectives swelling that subsided after two days. gration of the attachment apparatus, of this article are to present a case The site healed uneventfully and which includes the gingival margins in which the surgical technique of loose sutures were removed over a (Figs 3 & 4). Orthodontic leveling of “lip repositioning” was used to re- period of four weeks. The remaining the gingival margins of the maxil- duce gingival display, and to suggest sutures were left to be resorbed. The lary teeth may be considered in this the technique’s use as an alternative patient was pleased with the esthetic 8 situation. Resective surgery is also treatment modality. outcome. Figure 8 shows the pa- possible but may expose the narrow tient at her three-month follow-up. root surface and necessitate a resto- It is important to establish A one-year follow-up photograph ration. the etiology responsible for the (Fig 9) shows stable results. The third possibility is vertical excessive gingival display. The procedure limits the retrac- maxillary excess in which there is an tion of the smile elevator muscles, enlarged vertical dimension of the thus reducing the gingival display midface and incompetent lips (Figs shown in a smile. 5 & 6). Treatment involves orthog- Case Report nathic surgery to restore normal in- The patient, a 25-year-old healthy Procedure ter-jaw relationships and to reduce female, presented to our private the gingival display9; this involves practice with a chief complaint of a Patients undergoing this proce- hospitalization and significant side “gummy smile” (Fig 7). She wanted dure should be healthy, with no peri- effects for patients. a procedure that would reduce the odontal disease or apparent pathol- ogy. The surgical site is anesthetized Finally, when the patient smiles, gingival display when she smiled. with a conventional anesthesia be- if the upper lip moves in an apical Her teeth had normal dimensions, tween the first maxillary molars. The direction and exposes the dentition and the width-to-height ratio was local infiltration is administered in and excessive gingivae, then surgical normal. A diagnosis of moderate the buccal vestibule with additional lip repositioning may be utilized to vertical maxillary excess was made. infiltration for hemostasis purposes. reduce the labial retraction of the An alternate treatment option of or- The incision outline is marked with elevator smile muscle and minimize thognathic surgery by an oral and a sterile pencil on the dried tissues. the gingival display. This procedure maxillofacial surgeon was discussed A partial-thickness incision is made was first described in the plastic with the patient. She preferred a less along the mucogingival junction. A surgery literature in 197310 and was invasive procedure to address her

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Figure 9: Postoperative smile after one year, Figure 10: Retracted view with digitally created displaying stable results. incision outline.

Figure 11: Exposed submucosa after removal of the Figure 12: Stabilization sutures in place. epithelial discard.

Figure 13: Continuous interlocking suturing. Figure 14: Postoperative retracted view after one week.

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Figure 15: Postoperative retracted view showing scar formation.

second parallel incision is made at Nonsteroidal anti-inflammatory nor salivary glands in one of their the labial mucosa at approximately medications (and occasionally, oral cases. This complication resolved on 10-12 mm distance from the first antibiotics) are administered post- its own as observed at the four-week incision. The two incisions are con- operatively. Patients are instructed follow-up. nected at the mesial line angles of to use ice compresses for several Variations in surgical lip reposi- the right maxillary first molar and hours and to minimize lip move- tioning have been reported in the the left maxillary first molar to cre- ment for one week. A one-week un- medical literature. Several articles ate an elliptical outline (Fig 10). In eventful healing pattern is shown in advocate severing the smile muscle the authors’ experience, the amount Figure 14. attachment to prevent relapse of the of tissue excision should be double Postoperative symptoms usu- smile muscle into its original posi- the amount of gingival display that ally include some mild discomfort tion13-15; this may also minimize the needs to be reduced, with a maxi- for several days and a feeling of flap tension during suturing. mum of 10-12 mm of tissue exci- “tension” when the patient smiles. sion. The epithelium is removed Loose sutures are removed over a pe- Surgical lip repositioning … in the incision outline, leaving the riod of four weeks and the remain- underlying submucosa exposed (Fig holds promise as an alternative ing sutures are left to be resorbed treatment modality in esthetic 11). Bleeding can be controlled by on their own. Follow-up examina- rehabilitation. an additional local anesthesia in- tions should reveal reduced gingival filtration and the use of electroco- display (Fig 8). After several weeks agulation. The two incision lines of healing, a scar formation can be Patients with minimally attached are approximated with Maxon 6/0 observed (Fig 15). Another patient gingivae may not be ideal candidates stabilization sutures (United States treated with surgical lip reposition- for this procedure due to potential Surgical, Tyco Healthcare Group; ing in conjunction with an esthetic difficulties in flap approximation Norwalk, CT) (Fig 12). Care should crown lengthening is shown in and suturing. Severe skeletal defor- be taken regarding proper alignment Figure 16 and Figure 17. mities are also contraindications for of the midline of the first and sec- The procedure is safe and has this procedure and should ideally be ond incision lines (lip midline and minimal side effects. Reports in the treated with orthognathic surgery. teeth midline). Once the flaps are literature12 and the authors’ expe- stabilized, an additional continu- rience have shown postoperative Conclusion ing interlocking suture is used to bruising, discomfort, and swelling secure complete closure. Pressure is Surgical lip repositioning is an of the upper lip to be minimal. The applied until hemostasis is achieved effective procedure to reduce gingi- authors have encountered mucocele (Fig 13). val display by positioning the upper formation due to severing of the mi- lip in a more coronal location. The

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Figure 16: Preoperative smile of a Figure 17: Postoperative smile after patient with moderate maxillary a lip repositioning procedure and an excess and delayed eruption. esthetic crown lengthening. Cosmetic Dentistry by Dr. William Dorfman. long-term stability of the results re- 5. Maynard JG Jr, Wilson RD. Physiologic 11. Rosenblatt A, Simon Z. Lip Repositioning mains to be seen, but it holds prom- dimensions of the periodontium signifi- for Reduction of Excessive Gingival Dis- cant to the restorative dentist. J Periodontol play: A Clinical Report. Int J Perio Rest Dent ise as an alternative treatment mo- 50:170-174, 1979. 26:433-437, 2006. dality in esthetic rehabilitation. 6. Lee EA. Aesthetic crown lengthening: 12. Kamer F. “How do I do it”—Plastic surgery, classification, biologic rationale, and practical suggestions on facial plastic sur- References treatment planning considerations. Pract gery, smile surgery. Laryngoscope 89:1528- 1. Crispin BJ, Watson JF. Margin placement Proced Aesthet Dent 16:769-778, 2004. 1532, 1979. of esthetic veneer crowns. Part I: Anterior 7. Chu SJ, Karabin S, Mistry S. Short tooth 13. Cachay-Velasquez H. Rhinoplasty and fa- tooth visibility. J Prosthet Dent 45:278-282, syndrome: diagnosis, etiology, and treat- cial expression. Ann Plast Surg 28:427-433, 1981. ment management. J Calif Dent Assoc 1992. 2. Vig RG, Brundo GC. The kinetics of ante- 32:143-152, 2004. 14. Miskinyar SAC. A new method for cor- rior tooth display. J Prosthet Dent 39: 502- 8. Kokich VG. Esthetics: the orthodontic- recting a gummy smile. Plast Reconstr Surg 504, 1978. periodontic restorative connection. Semin 72:397-400, 1983. 3. Kokich VO Jr, Kiyak HA, Shapiro PA. Com- Orthod 2:21-30, 1996. 15. Litton C, Fournier P. Simple surgical cor- paring the perception of dentists and lay 9. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, rection of the gummy smile. Plast Reconstr people to altered dental esthetics. J Esthet Arregui JS. New approach to the gummy Surg 63:372-373, 1984. Dent 11:311-324, 1999. smile. Plast Reconstr Surg 104:1143-1150; ______4. Garguilo A, Wenz F, Orban B. Dimensions discussion 1151-1152, 1999. v and relations at the dentogingival junc- 10. Rubinstein AM, Kostianovsky AS. Cirugia tion in humans. J Periodontol 132:261-267, estetica de la malformacion de la sonrisa. 1961. Pren Med Argent 60:952, 1973.

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