October 1, 2014
by Claude G. Ibbott, BSc, DMD, FRCD(C); Angel Carlson-Fedyk, CDA, RDH; Whitney Love, RDH
EGD has been referred to as a “gummy smile”. The amount of gingiva showing in a normal full smile is 1-2mm. A display of 4mm or more of gingival exposure is considered unattractive. The incidence of EGD may approximate 14 percent in females and 7 percent in males.1 Hyperfunction of the lip elevator muscles often results in EGD2 and is the primary factor when lip length is normal and the lower third of the face is proportional to the other thirds. A differential diagnosis of EGD must include an examination for delayed eruption, orthodontic problems, and skeletal deformities. Some cases may require complex treatment involving crown lengthening, orthodontics, orthognathic surgery, lip positioning surgery and restorative dentistry. The three Cases presented here include one case requiring crown lengthening before lip positioning and two Cases requiring lip positioning alone. The Cases illustrated here have normal lip length and a proportional face.
All three Cases illustrated here had similar surgery. Local anesthetic (xylocaine 2 percent with epinephrine 1:100,000) and 1:50,000 for bleeding control was used. Coronal incisions were made with a #15 blade along the MG line and extending to the first or second bicuspid. The incision width was roughly two times the amount of gingival display. The coronal and apical incisions met in the bicuspid regions in a rounded fashion. The frenum between the two centrals was left intact as a reference point so the incisions did not extend across the mid-line (Fig. 1). The epithelium was dissected as a partial thickness flap using a mosquito forceps to hold the tissue. The mucosal flap was advanced and sutured at the muco-gingival line using interrupted 5-0 sutures (Figs. 2 & 3). The patients were all able to have ibuprofen 600 mg four times daily and amoxicillin 500 mg three times daily for a week. Each patient treated had little swelling or pain. Ice packs were applied as needed and 0.12 percent chlorhexidine was used twice daily for cleansing of the area. Sutures were removed at two weeks. (Fig. 4). Slight scarring was evident at the MG line but not visible. Contra- indications to surgery would be inadequate attached tissue, short upper lip, minimal vestibule and excessive VME.
This 53-year-old female has been a non-smoker for 10 years. Intraoral examination revealed excellent periodontal health and excellent restorative dentistry. An adequate vestibule and a good zone of attached gingiva were noted. Her lip length was 20mm (normal), the lower 1/3 of her face was proportional to the other thirds and there were no issues with her occlusal plane. Her smile was asymmetrical and lifting to the right side (7mm. gingiva showing on the right and about 5mm to tooth #23 on the left). Her upper lip was thin and stretched. She expressed an interest in showing less gingiva and having a fuller upper lip. She understood that her asymmetry was a genetic trait from her father. This patient had no health issues and no allergies to any medications. A diagnosis of hypermobile upper lip was made. She consented to surgery. The apical incision on the right side was made 2mm. wider than the left side. There was no swelling and little pain with the procedure. She was pleased with the result as the smile is now more symmetrical and the upper lip has appeared to have increased in volume. The result is stable at four months (Figs. 5 & 6).
This 45-year-old woman was a non-smoker. Her periodontal health was very good. She had extensive restorative therapy to correct her smile but remained extremely unhappy with her smile. She had an adequate vestibule and adequate attached gingiva. Her lip length was 22mm (normal) and the lower third of her face was proportional to the other thirds. There were no issues with her occlusal plane. She showed 8mm of gingiva with a full smile. She was also conscious of a thin upper lip. A diagnosis of hypermobile upper lip was made and she consented to surgery. She had little swelling or pain and was delighted with the result of the procedure. She was most pleased with the appearance of the upper lip, which had more than tripled in thickness after surgery (Figs. 7 & 8).
This 32-year-old female reported she has, “hated her smile since she was a young girl”. The only intra-oral issues noted were a rotated right lateral incisor and a retained deciduous tooth upper right segment (Impacted cuspid). Her main concern was her “gummy smile”. Restorative work to improve the appearance of #12 and the deciduous tooth would be done after the lip surgery. Examination showed a normal lip length and a proportional lower third of the face. This patient was in excellent health and was a non-smoker. Gingival tissues were on enamel and it was determined that crown lengthening would be required before lip surgery (Fig. 9). Crown lengthening was done (Fig. 10) and after only one week of healing, lip surgery was done (Fig. 11). The patient had little discomfort and was thrilled with the result (Figs. 10 & 13).
Lip repositioning surgery is a relatively simple procedure, which has few post-op complications and may be a permanent treatment for excessive gingival display. This procedure also is successful in increasing lip volume and for the correction of an asymmetrical smile. Most importantly, the three patients included in this article each expressed great satisfaction with the appearance of their smiles following the procedure. Studies3,5 indicate that results are stable for up to a year. Longer term studies will be reported. OH
Claude G. Ibbott BSc,, DMD, FRCD(C) has served as President of the Canadian Academy of Periodontology, has been an examiner for the Royal College of Dentists of Canada and has been a clinical Assistant Professor (University of Manitoba). He has published and lectured internationally.
Oral Health welcomes this original article.
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2. Ezquerra F, Berrazuenta MJ, Ruiz-Capillas A, Arragui JS, New approach to the gummy smile, Plast Reconstr Surg 1999:104:1143-1150 discussion 1151-1152.
3. Rosenblatt A, Simon Z, Lip repositioning for reduction of excessive gingival display: A clinical report. Int. J. Periodontics Restorative Dent 2006:26:433-437.
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5. Hurmayun N, Kolhatkar S, Soulyas J, Bhola M , Mucosal coronally positioned flap for the management of excessive gingival display in the presence of hypermobility of the upper lip and vertical maxillary excess. J Periodontol Vol 81 Number 12: 1858-1863