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A modified technique that decreases the height of the upper lip in the treatment
of gummy smile patients: A case series study

Article · January 2012

DOI: 10.5897/JDOH12.004

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Journal of Dentistry and Oral Hygiene Vol. 4(3), pp. 21-28, November 2012
Available online at http://www.academicjournals.org/JDOH
DOI:10.5897/JDOH12.004
ISSN 2141-2472 ©2011 Academic Journals

Case Report

A modified technique that decreases the height of the

upper lip in the treatment of gummy smile patients: A
case series study
Fernando Salimon Ribeiro*, Fernando Cavalcante Castro Garção, Alex Tadeu Martins, Celso
Eduardo Sakakura, Benedicto Egbert Corrêa de Toledo and Ana Emília Farias Pontes
Curso de Mestrado em Ciências Odontológicas - UNIFEB. Av. Prof. Roberto Frade Monte, 389. Bairro Aeroporto. Zip
Code: 14783-226. Barretos, SP, Brazil.
Accepted 28 June, 2012

Delayed passive eruption is conventionally treated with osteotomy and osteoplasty, which is limited to
the vicinity of cementoenamel junction. The aim of the present study was to evaluate clinical outcome
of three gummy smile patients with delayed passive eruption submitted to an extended osteoplasty in
the buccal aspect of anterior maxilla. Digital photograph images of maximal smile were taken in order to
assess the results before and 9 months after surgery. All maxillary incisors were evaluated. In
comparison with baseline, all patients presented lip dropping (calculated in 7.9 ± 1.7%), increase in
crown length (18.2 ± 2.7%), and a decrease in the gingival display (46.6 ± 2.7%). On the other hand,
considering specifically the decrease in gingival display, 19.7 ± 3.8% of it was due to the amount of lip
dropping, while 26.9 ± 1.2% was due to the increase in crown length. Within the limits of the present
study, it could be concluded that after the extended osteoplasty, upper lip has slightly dropped and was
less tensioned, which provided a more harmonious smile.

Key words: Gum, smiling, osteoplasty, mucogingival surgery, aesthetics.

INTRODUCTION

Smile is considered an important aesthetic reference, hyperactivity, gingival overgrowth, delayed passive erup-
thus, the study of the alterations that lead to its dishar- tion (DPE), vertical maxillary excess (VME), or a combi-
mony, as well as, the techniques used for its correction nation of them (Robbins, 1999; Monaco et al., 2004).
have played a rather more relevant role within dentistry. Labial hyperactivity is characterized by marked contrac-
Gingiva excessive exposure during smile is also referred tion of the upper lip elevator muscles. Some approaches
to as “gummy smile”, being diagnosed in cases where, are proposed to contain labial movement, such as
during smile, gingival display measures more than 3 mm surgical procedures (Rosenblatt and Simon, 2006;
from its margin up to the upper lip line (Allen, 1988; Jorgensen and Nowzari, 2001) or use of medication
Garber and Salama, 1996). It might be caused by labial (Polo, 2005). An alternative is a surgical procedure to
remove a strip of alveolar mucosa, described to reduce
oral vestibule in the anterior region, and thus, reduce
labial elevation (Rosenblatt and Simon, 2006; Litton and
*Corresponding author. E-mail: Fournier, 1979; Humayun et al., 2010). In these cases,
[email protected]. Tel: +55 (17) 3321-6468. Fax: the short-term result is satisfactory; however, in long-term
(17) 3321-6412. periods, they are discouraging (Rosenblatt and Simon,
Abbreviations: DPE, Delayed passive eruption; VME, vertical
2006) due to the possibility of recurrence. Surgeries that
maxillary excess; HLL, the height of the lip line; LC, length of aim muscular amputation to limit labial elevation during
the crown; LG, length of gingiva; CC, spearman correlation smile, on their turn, show satisfactory outcomes
coefficient. (Miskinyar, 1983; Jorgensen and Nowzari, 2001);
22 J. Dent. Oral Hyg.

Figure 1. Initial aspect of the (a) smile, and an (a) intraoral view of Case 1.

nevertheless, there is always the risk of paresthesia. excess in the buccal aspect of the anterior teeth roots.
Administration of botulinum toxin (type A) led to a This procedure resulted in expressive aesthetic improve-
satisfactory effect, although temporary, and reappli- ment, not only for the adequacy of bone-gingiva architect-
cations are required at intervals of 3 to 6 months (Polo, ture, but also for allowing a better adaptation of the upper
2005). lip, nevertheless, clinical parameters were not quantified.
Gingival overgrowth can also affect the smile aesthetic. The aim of the present study was to evaluate clinical
This alteration can be caused by specific medicaments, outcome of gummy smile patients with delayed passive
hereditary, hormonal, or idiopathic factors (Wynne et al., eruption submitted to an extended osteoplasty in the
1995). Its correction is well described in dental literature, buccal aspect of anterior maxilla.
and is performed by means of gingivectomy or
gingivoplasty (Goldman, 1951; Levine and McGuire,
1997; Coslet et al., 1977). CASE REPORTS
The VME is an osseous developmental alteration, also
Three young adult female subjects with DPE and submitted to
referred to as long face syndrome. Subjects commonly surgery to correct gummy smile in the clinic of Periodontology at the
show a normal upper third of the face; the medium third São Paulo State University – UNESP, were included in the present
has narrow nose and nostril base; and the lower third is study. The patients sought for treatment for being dissatisfied with
elongated. Commonly, there is a long interlabial distance, their smile aspect due to excessive exposure of gingiva. This study
which may or not be associated with open bite; maxillary was conducted according to the Declaration of Helsinki, and all
anterior teeth excessive display or even complete patients gave their informed consent.
DPE diagnosis was based on the clinical evaluation of the
exposure when lips are in rest position; and excessive crowns, and through osseous probing. All the patients had short
exposure of the gingiva during smile (Schendel et al., clinical crowns, and at least two buccal sites (among teeth 13 to
1976). To correct this syndrome, orthognatic surgeries 23) with the distance from the cementoenamel junction to the lower
(Le Fort I) with anterior maxillary intrusion are indicated, bone crest inferior or equal to 1.0 mm, evaluated under anesthesia
usually preceded by orthodontic therapy (Redlich et al., with the use of a North Carolina periodontal probe (HU-FRIEDY,
Chicago, IL, USA).
1999; Ataoglu et al., 1999; Fowler, 1999).
Patients were in good general health, did not take any medication
Finally, DPE is characterized by alterations during the and were with no tobacco habit reported. Prior to surgery, patients
passive phase of eruption, allowing the crestal bone to be were submitted to basic periodontal therapy, and the sites operated
maintained very close or at the cementoenamel junction did not present marginal bleeding, bleeding on probing, or probing
level, preventing the gingival tissue to assume its appro- depth higher than 3 mm. All the patients had a strip of attached
priate physiological apical positioning (Duarte et al., gingiva wider than or equal to 5 mm.
2001). Thus, marginal gingiva covers most part of dental
crown, making it short, and increasing gingival exposure Case 1
during smile. Conventionally, its treatment involves inter-
nally beveled incision or intrasulcular incision; followed by A 25-old female was diagnosed with DPE associated with VME
osteotomy; and osteoplasty, which is limited to the (Figure 1). On radiographic examination, the pre-sence of radicular
proximity of the crown (Allen, 1988; Levine and McGuire, resorptions had been detected, probably due to previous
orthodontic therapy. Thus, treat-ment plan included periodontal
1997; Coslet et al., 1977; Narayan et al., 2011). However, surgery with osteotomy and osteoplasty, after that patient was
Ribeiro et al. (2004) described a case of DPE in which an guided for orthognatic surgery. In this case, minimal osteotomy was
extended osteoplasty was carried out to remove bone planned, to prevent from greater loss of supporting bone, while
 Ribeiro et al. 23

Figure 2. In Case 1 patient: (a) internal-beveled and intramuscular incisions were performed in the
buccal aspect of teeth 14 to 24; in the distal of which releasing incisions were carried out; (b) a
mucoperiosteal flap was elevated to expose the buccal aspect of alveolar bone; (c) the osteoplasty
was initiated with groove creation to guide the amount of bone to be removed; (d) the grooves were
then connected, respecting patient’s anatomy, and the osteotomy was performed. Then, (e) the flaps
were repositioned and sutured and (f) sutures were removed 5 days after surgery.

osteoplasty was extended, to improve gingival architecture. process, the gingiva could follow this architecture. After that,
Surgical sequence of events described here was also performed osteotomy was performed in buccal aspect to lengthen the clinical
for the other patients and only the amount of bone removal varied. crown (Figure 2d), with chisels and periodontal curettes. In this
Initially, local anesthesia was given with 2% mepivacaine HCl with case, a distance of 1.0 to 1.5 mm was maintained between bone
epinephrine 1: 100.000 (SEPTODONT, Saint-Maur des Fossés, crest and cementoenamel junction. The amount of bone removal
France). Bleeding points were created in buccal aspect of the varies to allow the maintenance of the height and contour of gingiva
gingiva, corresponding to the height of cementoenamel junction. An in harmony with normal pattern, with crestal bone level of the
internally beveled incision was performed slightly coronally to the central incisors in an apical position in comparison to the lateral
bleeding points (Figure 2a), which was followed by an intrasulcular incisors, and at the level of the canines. In current case, special
incision, and then releasing incisions. A mucoperiosteal flap was care was also taken to maintain at least a 1: 1 crown to root ratio.
raised (Figure 2b), and the tissue collar was removed. Then, Finally, the flap was repositioned and sutured with continuous sling
osteoplasty was carried out under copious saline irrigation with the sutures (Figure 2e), which were removed 5 days after surgery
aid of a round diamond bur of gross granulation mounted in high- (Figure 2f). Schematic drawings of the surgical procedures are
speed handpiece. Initially, in the interdental area, grooves were presented in Figures 3 and 4.
created to guide bone removal (Figure 2c). The grooves were Amoxicillin 500 mg, a capsule 3 times a day for 7 days starting 1
linked main-taining an anatomic contour, so that the excess of bone h before surgery was prescribed to the patient, along with anti-
tissue over the roots was removed, so that after the healing inflammatory piroxicam 20 mg, a tablet a day for 4 days starting 1 h
24 J. Dent. Oral Hyg.

Figure 3. Schematic drawing of the surgery in a frontal view: (a) Grooves were surgically created in the interdental
areas, and then (b) linked to remove the excess of bone. Final aspect after (c) osteoplasty, and (d) osteotomy.

Figure 4. Schematic drawing of the surgery in a lateral view, (a) previously and (b) after osteoplasty; and (c) after
osteotomy.

before surgery; and mouth-rinse with 0.12% chlorhexidine instructed on how to maintain the hygiene of the wound area, and
digluconate solution for 1 min, twice a day for 7 days. Patient was was followed-up bi-weekly to motivate oral hygiene performance
 Ribeiro et al. 25

Figure 5. Aspect of Case 1 (a) at smile, and (b) an intraoral view, 9 months after surgery.

Figure 6. Aspect of Case 2 (a) at baseline, and (b) 9 months after surgery. Note that lips were less tensioned in
maximum smile.

up to the first month, monthly up to the third month, and finally Image assessment
recalled 9 months after surgery (Figure 5) for clinical evaluation.
Facial photographs in maximum smile were used for analysis
(Strauss et al., 1997). As proposed by Peck et al. (1992), to reach
Case 2 the maximum smile, each subject was trained to achieve the same
lip configuration at least twice successively before any photograph
A 24 year-old female (Figure 6) was presented with DPE. was taken. To analyze the photographs, appropriate software was
Osteotomy was performed to maintain crestal bone 2 to 3 mm used (IMAGEJ 1.34, National Institutes of Health, Bethesda, MA,
apical to cementoenamel junction, while osteoplasty was USA). A vertical line was drawn in each tooth from 12 to 22, from
performed as previously described. Patient was followed-up for the incisal border, passing through the zenith, up to the inferior
9 months as previously described. border of the lip. The parameters corresponded to the height of the
lip line (HLL), which was divided into the length of the crown (LC),
and the length of gingiva (LG). To calibrate the images obtained in
Case 3 different periods, all values were transformed into a ratio,
considering the length of periodontal probe in both photographs
A 27-year-old female (Figure 7), presented with DPE was treated by (Figure 8). Each measure was performed in triplicate, recorded at
means of osteotomy and osteoplasty as pre-viously described. least one day apart, and their mean values were representative of
Osteotomy was performed to maintain crestal bone 2 to 3 mm each tooth. Mean values of all teeth were representative of the
apical to cementoenamel junc-tion. Patient was submitted to a subject. The values were expressed in percentage.
provisional crown recon-touring 6 months after surgery to close the One examiner (AEFP) performed all measurements, and intra-
diastemas, and was also followed-up for 9 months. Surgical proce- examiner reliability was determined by calculating the Spearman
dures were well tolerated, and neither pain nor postoperative correlation coefficient (CC) between the first and second measure
discomforts were reported. (CC = 0.998, p = 0.0000), the second and third measure (CC =
26 J. Dent. Oral Hyg.

Figure 7. Aspect of Case 3 (a) at baseline, and (b) 9 months after surgery. This patient had been submitted to crown
recontouring 6 months after surgery.

Figure 8. Clinical measurements were performed considering the length of the crown (LC), length of the
gingiva (LG) and the height of lip line (HLL). (*) A periodontal probe was used as reference for calibration
(Case 1 patient).

0.998, p = 0.0000), and the first and third measure (CC = 0.998, p = with baseline, all patients presented lip dropping (mean
0.0000). HLL was reduced 7.9 ± 1.7%), increase in crown length
(mean LC was increased 18.2 ± 2.7%), and a decrease in
the gingival display (mean LG was reduced 46.6 ± 2.7%).
RESULTS On the other hand, considering specifically the decrease
in gingival display, 19.7 ± 3.8% of it was due to the
Mean values from each patient at baseline and after amount of lip dropping, while 26.9 ± 1.2% was due to the
surgery were presented in Table 1. Briefly, in comparison increase in crown length (Figure 9).
 Ribeiro et al. 27

Table 1. Values in percentage, means and standard deviations (SD) of the length of the crown (LC),
length of the gingiva (LG) and the height of lip line (HLL) at baseline and 9 months after, and their
variation for each patient.

Case Parameter Baseline (%) Final (%) Variation (%)

LC 63.3 73.1 15.3
1 LG 36.7 19.9 -45.7
HLL 100.0 93.0 -7.0

LC 58.2 69.1 18.6

2 LG 41.8 21.0 -49.7
HLL 100.0 90.1 -9.9

LC 57.7 69.7 20.7

3 LG 42.3 23.5 -44.4
HLL 100.0 93.2 -6.8

LC 59.8 ± 3.1 70.6 ± 2.2 18.2 ± 2.7

Mean ± SD LG 40.2 ±3.1 21.5 ± 1.8 -46.6 ± 2.7
HLL 100.0 ± 0.0 92.1 ± 1.7 -7.9 ± 1.7

Figure 9. Schematic drawing (mean values in percentage) describing the role of lip dropping and
crown lengthening in the reduction of gingival exposure at smiling. These values were calculated
considering initial length of gingiva as 100%.

DISCUSSION McGuire, 1997). However, a common observation in

gummy smile case is the presence of a thick and irregular
In the current literature, the treatment of DPE involves bone plate in the buccal aspect of anterior teeth, which
clinical crown lengthening (Allen, 1988; Levine and tensions and displaces the lip to a more coronal position
28 J. Dent. Oral Hyg

during smile, increasing gingival exposure. Our clinical nathic surgery in a patient with long face: A case report. Int. J.
experience led us to give special attention to the removal Adult Orthodon. Orthognath. Surg. 14:304-309.
Coslet JG, Vanarsdall R, Weisgold A (1977). Diagnosis and
of the excessive bone volume by means of an extended classification of delayed passive eruption of the dentogingival
osteoplasty. This procedure focuses on the removal of junction in the adult. Alpha Omegan 70:24-28.
bone thickness, and does not affect tooth support, thus, Duarte CA, Castro MVM, Pereira CA, Pereira AL (2001). Esthetic
long-term injuries are not expected. It should also be Periodontal Surgery. In: Duarte CA. Preprosthetic and Esthetic
considered that, for not being pathologic, gummy smile Periodontal Surgery, 2nd edition. (In portuguese). Livraria Editora
must be treated only if the patient is dissatisfied with Santos, Sao Paulo. pp. 341-406.
Fowler P (1999). Orthodontics and orthognathic surgery in the
his/her own appearance, as the proper diagnosis must combined treatment of an excessively "gummy smile". N. Z. Dent.
always precede the choice for the best technique to be J. 95:53-54.
used. Garber DA, Salama MA (1996). The aesthetic smile: Diagnosis and
The role of the extended osteoplasty in the height of the treatment. Periodontology 2000. 11:18-28.
upper lip was more evident in Case 1, where osteotomy Goldman HM (1951). Gingivectomy. Oral Surg. Oral Med. Oral
Pathol. 4:1136-1157.
was minimal. Thus, although LC presented the smaller
Humayun N, Kolhatkar S, Souiyas J, Bhola M (2010). Mucosal
amount of increase (15.3%), there was an expre-ssive coronally positioned flap for the management of excessive
reduction in gingival exposure (45.7%) and labial gingival display in the presence of hypermobility of the upper lip
dropping (7.0%). and vertical maxillary excess: A case report. J. Periodontol.
More expressive reduction in gingival exposure (49.7%) 81:1858-1863.
and labial dropping (9.9%) were observed in Case 2, Johnston DJ, Millett DT, Ayoub AF, Bock M (2003). Are facial
expressions reproducible? Cleft Palate Craniofac. J. 40:291-296.
because of the anatomic characteristic of the patient that Jorgensen MG, Nowzari H (2001). Aesthetic crown lengthening.
presented the greatest amount of bone at baseline. Periodontology 27(1):45-58.
In its turn, Case 3 patient had been submitted to a Levine RA, McGuire M (1997). The diagnosis and treatment of the
provisional crown recontouring 6 months after surgery. gummy smile. Compend. Contin. Educ. Dent. 18:757-762.
The use of a restorative material in the incisal portion of Litton C, Fournier P (1979). Simple surgical correction of the
the crowns may explain the greatest mean increase of LC gummy smile. Plast. Reconstr. Surg. 63:372-373.
Miskinyar SA (1983). A new method for correcting a gummy smile.
observed among the patients (20.7%). With regard to the Plast. Reconstr. Surg. 72:397-400.
methodology used in the present study, the image of Monaco A, Streni O, Marci MC, Marzo G, Gatto R, Giannoni M
maximal smile was used for measurements because it (2004). Gummy smile: Clinical parameters useful for diagnosis
was considered more reproducible than natural smile, and therapeutical approach. J. Clin. Pediatr. Dent. 29:19-25.
particularly, in female subjects (Johnston et al., 2003). In Narayan S, Narayan TV, Jacob PC (2011). Correction of gummy
smile: A report of two cases. J. Ind. Soc. Periodontol. 15:421-4
addition, the assessment of the images was carried out
Peck S, Peck L, Kataja M (1992). The gingival smile line. Angle
as proposed by Peck et al. (1992), in whose study, the Orthod. 62:91-100.
standard error of the upper lip line measurement at Polo M (2005). Botulinum toxin type A in the treatment of excessive
maximum smile was 0.18 mm, which could be considered gingival display. Am. J. Orthod. Dentofacial Orthop. 127:214-218.
clinically irrelevant. However, a randomized controlled Redlich M, Mazor Z, Brezniak N (1999). Severe high Angle Class II
clinical trial should be conducted to clarify the clinical Division 1 malocclusion with vertical maxillary excess and gummy
smile: A case report. Am. J. Orthod. Dentofacial Orthop. 116:
benefits of this protocol. 317-320.
Ribeiro FS, Pontes AEF, Garcia RV, Rapp GE (2004). Surgical
management of gummy smile caused by delayed passive
Conclusion eruption: A case report. J. Ind. Acad. Aesthet. Cosmet. Dent. 2:9-
11.
In conclusion, the completion of the surgical protocol Robbins JW (1999). Differential diagnosis and treatment of excess
gingival display. Pract. Periodontics. Aesthet. Dent. 11:265-272.
proposed resulted in clinical crown increase and Rosenblatt A, Simon Z (2006). Lip repositioning for reduction of
reduction of gingival exposure in the patients. excessive gingival display: A clinical report. Int. J. Periodontics
Furthermore, the upper lip slightly dropped and was Restor. Dent. 26: 433-437.
less tensioned, which provided a more harmonic aspect Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ
to the patients. These results suggest that the technique (1976). The long face syndrome: Vertical maxillary excess. Am.
J. Orthod. 70:398-408.
presented is a useful resource for esthetic improvements
Strauss RA, Weis BD, Lindauer SJ, Rebellato J, Isaacson RJ
in gummy smile patients. (1997). Variability of facial photographs for use in treatment
planning for orthodontics and orthognathic surgery. Int. J. Adult
Orthodon. Orthognath. Surg. 12:197-203.
REFERENCES Wynne SE, Aldred MJ, Bartold PM (1995). Hereditary gingival
fibromatosis associated with hearing loss and supernumerary
Allen EP (1988). Use of mucogingival surgical procedures to teeth: A new syndrome. J. Periodontol. 66:75-79.
enhance esthetics. Dent. Clin. North Am. 32:307-330.
Ataoglu H, Uckan S, Karaman AI, Uyar Y (1999). Bimaxillaryorthog-

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