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LIP REPOSITIONING :
AN ALTERNATIVE TREATMENT
OF GUMMY SMILE
Saidina Hamzah Daliemunthe

Ketua IPERI Komisariat Medan
4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016
Nomahn Humayun,* Shilpa Kolhatkar,* Jason Souiyas,† and Monish Bhola*
Mucosal Coronally Positioned Flap for the Management of Excessive Gingival
Display in the Presence of Hypermobility of the Upper Lip and Vertical Maxillary
Excess: A Case Report. J Periodontol 2010;81:1858-1863.
A smile is an important non-verbal method of

communication and is an interaction between
the teeth, the lip framework, and the gingival
scaffold.
In the western world,
a medium smile line
with minimal gingival
display (GD) is
considered to be
the most pleasing.

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.
Eliminating a Gummy Smile with Surgical Lip Repositioning.
Excessive gingival display, commonly

referred to as a “gummy smile,” can be a
source of embarrassment for some patients.

Sheth T, Shah S, Shah M and Shah E.
Lip Repositioning Surgery: A New Call in Periodontics.
Contemp. Clin. Dent 2013; 4(3): 378 – 381.
A normal gingival display between the inferior

border of the upper lip and the gingival margin of
the central incisors during a normal smile is 1-2 mm.
In contrast, an excessive gingiva-to-lip distance of 4
mm or more is classified as unattractive.

Nomahn Humayun,* Shilpa Kolhatkar,* Jason Souiyas,† and Monish Bhola*
Mucosal Coronally Positioned Flap for the Management of Excessive Gingival
Display in the Presence of Hypermobility of the Upper Lip and Vertical Maxillary
Excess: A Case Report
J Periodontol 2010;81:1858-1863.
In a sample of over 450 adults, aged 20 to 30

years, 7% of men and 14% of women were
PREVALENCE
found to have a gummy smile.
Dayakar MM, Gupta S and Shivananda H.
Lip Repositioning: An Alternative Cosmetic Treatment for Gummy Smile.
J Indian Soc Periodontol 2014; 18(4): 520 -523.
It is an aesthetic concern that can affect a

large portion of the population, with a
reported prevalence between 10.5% and 29%.
Sheth T, Shah S, Shah M and Shah E.
LIP LINE
Lip Repositioning Surgery: A New Call in Periodontics.
Contemp. Clin. Dent 2013; 4(3): 378 – 381.

First, it may be a result of delayed eruption in
which the gingivae fail to complete the apical
migration over the maxillary teeth to a
position that is 1 mm coronal to the cement-
enamel junctions.
Etiologies

The second possible cause is compensatory
eruption of the maxillary teeth with
concomitant coronal migration of the
attachment apparatus, which includes the
gingival margins
eruption of the maxillary
teeth with concomitant coronal migration
of the attachment apparatus,
which includes the gingival margins

The third etiology is a dentoalveolar extrusion.
Patients with a dentoalveolar extrusion must be
treated by an orthodontist or through
orthognathic surgery.

The fourth possibility is vertical maxillary
excess in which there is an enlarged vertical
dimension of the midface and incompetent
lips.

The fifth etiology is a short upper lip
(measured from the subnasale to the inferior
border of the upper lip). The average length of
the maxillary lip is 20 to 22 mm in young adult
females andThe22 to 24 mm in young
second possible cause is compensatory
adult
males. eruption of the maxillary

The sixth etiology is a hyperactive upper lip.
The fourth etiology is a hyperactive upper lip
Normally at repose 3 – 4 In hyperactive lip, the lip

mm of central incisors is may translate 1,5 to 2
exposed, and at full times more than the
smile entire crown (10 – normal normal distance.
11) mm is exposed.
IDENTIFICATION OF
ETIOLOGIC FACTORSteeth with concomitant coronal migration


Incisor Display at Rest

Assessment of the upper lip relative to the
incisal edges of the the maxillary incisors

at rest.
Normal incisor display : 3 – 4 mm.
Upper Lip Length
The average lip length at rest, as measured
from subnasale to the most inferior portion
of the upper lip at the midline, is about
23 mm in males and 20 mm in females.
Normal lip length Short upper lip

Clinical Crown Length
Vertical height of the central

maxillary
The second possible incisor in adult is
cause is compensatory
normally
teeth with concomitant coronal between
migration 9 – 12 mm,
with
of the attachment an average of:
apparatus,
▪ 10,6 mm in males, and
▪ 9,5 mm in females.

Short Clinical Crown Length
Incisal attrition

No attrition
Altered passive eruption Gingival overgrowth

Hypermobile Upper Lip
Extreme elevation of the

upper lip on smile due to
hyperfunction of the
elevator muscles.
• The average elevation of the upper lip on
smile is 7 – 8 mm.
• Apical movement of the upper lip, from
rest to maximum smile, is more than
9 – 10 mm.
Normal Lip Length
Harmonious occlusal plane
Vertical Maxillary Excess

(VME)
VME
Rest position Smile view

Normal Lip Length
Difference between
anterior and posterior
occlusal planes
Incisor overeruption
Excessive Gingival Display (EGD)
Incisor exposure during rest
Normal (3 – 4 mm)
Short clinical Normal clinical
More than 3
crown
The
– 4 mm
length
second possible cause is compensatorycrown length
No attrition
Incisal attrition
Hypermobility
Differential diagnosis Upper lip
Altered passive Gingival Incisor
eruption overgrowth overeruption
(1 or more teeth) (compensatory)
Excessive Gingival Display (EGD)
Incisor exposure during rest
More than 3 – 4 mm
Normal (3 – 4 mm)
Difference between anterior Harmonious

and posterior occlusal planes occlusal plane
Incisor overeruption VME

TREATMENTThe second possible cause is compensatory
Depends on the etiologic factors

•Altered passive eruption
Crown lengthening

•Incisor overeruption

Orthodontic
intrusion

•Gingival overgrowth
Gingivectomy


•Vertical Maxillary Excess
Combined Orthodontic – Surgical Treatment


•Short upper lip
•Hypermobile upper lip
Lip repositioning

•Administering the local anaesthetic in the
vestibular mucosa and lip.
•Outline the incision.
SURGICAL
PROCEDURES

•Partial thickness incision from the mesial line
angle of the first molar of one side to the
mesial line angle of the first molar on the
other side.
•Second partial thickness incision, parallel to
the first incision, in the labial mucosa,
10 – 12 mm apical to mucogingival junction.
•The incisions are connected at each first
molar, creating antheelleptical
which includes gingival margins outline.
•Removed the epthelium within the outline of

the incisions, leaving the underlying
connective tissue exposed. Be careful not to
make damage on the salivary glands in the
submucosa.

Amount of tissue excision
2a mm
a mm
± 10 – 12 mm

• Stabilization sutures to approximated the two
incision lines. Care should be taken
regarding proper alignment of the midline of
the first and second incision lines (lip
midline and teeth midline).

• Once the flaps are stabilized, an additional
interlocking suture is used to secure
complete closure.
Pressure is applied until hemostasis is
achieved

Modification of incision


Modification of suturing
•Parallel incised margins were approximated with
an interrupted stabilization suture at the midline to
ensure proper alignment of the midline of the lip
with that of the teeth .
•Multiple interrupted sutures at a distance of 1 mm
were taken on either side of the midline suture to
approximate the flap margins.

•Periodontal dressing is not a must.
•Nonsteroidal anti-inflammatory medications
(and occasionally, oral antibiotics) are
prescribed postoperatively.
One week postoperative Scar formation postoperative

Post-operative instructions :
▪ Soft diet
▪ Limited facial movements
▪ No brushing around the surgical site for
2 weeks The second possible cause is compensatory
▪ Placing ice packs over the upper lip
▪ Rinse gently with
of the attachment0,2 % chlorhexidine
apparatus,
gluconate or other antiseptic mouth rinse
twice daily for 2 weeks.
• Sutures are removed after 2 weeks.

Post operative symptoms :
▪ Mild pain and swelling .
▪ Feeling of tension on the upper lip while
talking or smiling, which lasted for one week.
Post operative healing :

▪ The site healed uneventfully with scar
formation at the suture line, which was
concealed under the lip and was not
apparent when the patient smiled.

Contra indication :
▪ Inadequate zone of attached gingiva.
▪ Severe skeletal drformities and severe VME.


PRE-OPERATIVE
18.11.2014
33 yrs
Laugh
CASE
Smile

Closed
Relaxof the attachment apparatus,

After incision
Suturing of the attachment apparatus,
Before incision

18.11.2014
After surgery
Before surgery

9 days post surgery

15 months post surgery
15 months post surgery
9 days post surgery

• Previous studies reported that a relapse can
occur after lip repositioning surgery.
▪ One of the most important predisposing

RELAPSE
factor forTherelapse iscause
second possible theis compensatory
biotype of
teeththe gingiva.
with concomitant
presence thin
coronal migration

• Asymmetry upon smiling could have been
encountered as an important complication.
▪ This can be avoided by:
1) Keeping labial frenulum intact at the
midline during the surgical procedure.
2) Keeping the same amounts of vertical
incisions on both sides of maxilla that
allowed removal of equal amounts of
mucosa on right and left operation
regions.

• Lip repositioning surgery is a relatively
simple procedure, which has few post
operative complications
• Surgical lip repositioning is an effective
CONCLUSION
procedure
positioning
to reduce gingival display by
the upper lip in a more coronal
location. ofwhich
the attachment apparatus,
includes the gingival margins
• It is an alternative option to improve the

gummy smile of a patient, provided
evaluation of the case is done to choose the
appropriate treatment option.
• It is less traumatic with fewer postoperative
complications and has a faster recovery time
compared to orthognathic surgery.
▪ The long-term stability of the results remains
to be seen, butofittheholds
eruption maxillary promise as an
alternativeof the
treatment modality in esthetic
attachment apparatus,
rehabilitation.

THANK YOU

The fifth etiology is a short upper lip
(measured from the subnasale to the inferior
border of the upper lip). The average length of
the maxillary lip is 20 to 22 mm in young adult
females andThe22 to 24 mm in young
second possible cause is compensatory
adult
males. eruption of the maxillary

Incisor Display at Rest

Assessment of the upper lip relative to the
incisal edges of the the maxillary incisors

at rest.
Normal incisor display : 3 – 4 mm.
Amount of tissue excision
2a mm
a mm
± 10 – 12 mm

Upper Lip Length
The average lip length at rest, as measured
from subnasale to the most inferior portion
of the upper lip at the midline, is about
23 mm in males and 20 mm in females.

Clinical Crown Length
Vertical height of the central

maxillary
The second possible incisor in adult is
cause is compensatory
normally
teeth with concomitant coronal between
migration 9 – 12 mm,
with
of the attachment an average of:
apparatus,
▪ 10,6 mm in males, and
▪ 9,5 mm in females.

Hypermobile Upper Lip
Extreme elevation of the

upper lip on smile due to
hyperfunction of the
elevator muscles.
• The average elevation of the upper lip on
smile is 7 – 8 mm.
• Apical movement of the upper lip, from
rest to maximum smile, is more than
9 – 10 mm.

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LIP REPOSITIONING :

Saidina Hamzah Daliemunthe

A smile is an important non-verbal method of

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

Excessive gingival display, commonly

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

A normal gingival display between the inferior

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

In a sample of over 450 adults, aged 20 to 30

It is an aesthetic concern that can affect a

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The fourth etiology is a hyperactive upper lip

Normally at repose 3 – 4 In hyperactive lip, the lip

ETIOLOGIC FACTORSteeth with concomitant coronal migration

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

incisal edges of the the maxillary incisors

Normal lip length Short upper lip

Vertical height of the central

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

Altered passive eruption Gingival overgrowth

Extreme elevation of the

Vertical Maxillary Excess

Rest position Smile view

Difference between anterior Harmonious

Incisor overeruption VME

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

•Removed the epthelium within the outline of

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

One week postoperative Scar formation postoperative

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

Post operative healing :

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

The second possible cause is compensatory

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016

4th NaSSiP ♦ GRAND ROYAL PANGHEGAR HOTEL ♦ BANDUNG ♦ 28 - 29 OKTOBER 2016