Laser-assisted lip repositioning surgery: Novel approach to treat gummy smile Sana Farista, Ramreddy Yeltiwar,1 Butchibabu Kalakonda,2 Kaustubh Suresh Thakare1

Consultant Periodontist, 1 Department of Periodontology, VYWS Dental College and Hospital, Amravati, Maharashtra, India, 2 Department of Preventive Dental Sciences, Al-Farabi Dental College, Riyadh, Saudi Arabia

Abstract: Excessive gingival display (EGD) resulting in a “gummy smile” is a major esthetic concern with ramifications in an individual’s personal and social life. Numerous treatment modalities have been used for the correction of EGD. The present case report describes the successful treatment of a young woman with an excess gingival display caused by a hyperactive upper lip and a mild vertical maxillary excess that was treated with a laser-assisted lip repositioning surgical technique accompanied by gingival recontouring. The procedure was accomplished by laser-assisted removal, through scraping a strip of mucosa from the maxillary buccal vestibule and suturing the mucosa of the lip to the mucogingival junction. This technique resulted in shortened vestibule and restricted the muscle pull of the elevator muscles of the lip, thereby reducing gingival display when the patient smiles. Laser-assisted lip repositioning surgery can be a viable, minimally invasive alternative to orthognathic surgery. Key words: Crown lengthening, diode laser, excessive gingival display, gummy smile, lip repositioning surgery

INTRODUCTION

Access this article online Website: www.jisponline.com DOI: 10.4103/jisp.jisp_411_16 Quick Response Code:

Address for correspondence: Dr. Kaustubh Suresh Thakare, Department of Periodontology, VYWS Dental College and Hospital, Amravati - 444 602, Maharashtra, India. E-mail: kaustubhthakaremds@ gmail.com Submission: 22-12-2016 Accepted: 07-09-2017 164

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n attractive smile goes a long way in enhancing a person’s self-confidence, whereas a “gummy” smile often becomes a matter of esthetic concern. The harmony of a perfect smile is determined not only by the shape, position, color of teeth, or the lip framework but more importantly by the gingiva, highlighting the vital role of gingiva upon the beauty of a person’s smile. The hallmark of the so-called “ideal smile” is the exposure of the entire length of maxillary teeth with 1 mm visibility of the midfacial maxillary gingiva.[1] Gingival exposure within a permissible limit of 3 mm may be considered esthetically acceptable. [1] However, a gingival display exceeding 3 mm is unpleasant and termed as “excessive gingival display (EGD)” or also known as “gummy smile.”[2] Although a gummy smile has limited impact on the functional capabilities, it does have a strong influence on the person’s psychology, posing a major obstacle in social interactions.

It is imperative that the treatment of EGD should include a proper diagnosis and involve a team work owing to the multiple factors that dictate the underlying cause of gummy smile. Among the various causes, APE was found to be one of the most common intraoral causes for gummy smile. Treatment of APE involves crown lengthening through gingivectomy and apically positioned flap with or without osseous resection and has been well documented in the literature.[2] EGD associated with a vertical maxillary excess is treated by orthognathic surgery performed by a maxillofacial surgeon in association with an orthodontist.[1] Patients diagnosed with an EGD associated with a hyperactive upper lip have been treated with numerous treatment options such as injection of botox (Botulinum toxin), severing and separation This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]

EGD results from varied etiologies; ranging from extraoral causes such as vertical maxillary excess, labial muscular hypermobility, and short upper lip to several other intraoral causes such as altered passive eruption (APE), compensatory eruption, or a combination of these.[2]

How to cite this article: Farista S, Yeltiwar R, Kalakonda B, Thakare KS. Laser-assisted lip repositioning surgery: Novel approach to treat gummy smile. J Indian Soc Periodontol 2017;21:164-8.

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Farista, et al.: Lip repositioning

of the lip muscles, myectomy or myotomy of the levator labii superioris muscles with accompanying frenectomy, and lip repositioning.[3] Lip repositioning was intended to minimize the gingival display during smile by removing a strip of mucosa and shortening the vestibular depth, thereby restricting the muscle pull of the elevator muscles responsible for smile (e.g., zygomaticus minor, orbicularis oris, levator anguli oris, and levator labii superioris). Rubenstein and Kostianovsky were the pioneers in introducing lip repositioning technique as part of plastic reconstructive surgery in the medical field for the correction of gummy smile associated with a hypermobile lip.[3] Rosenblatt and Simon modified this procedure and adapted this for better use in dentistry.[4] Conventional lip repositioning resulted in increased patient morbidity owing to the scalpel being utilized to remove the strip of the labial mucosa and the frenum. The use of a scalpel resulted in bleeding with decreased visibility in the operatory field, postoperative swelling, and bruising.[1] Hence, the present case report was an attempt to use the laser to assist removal of the strip of the labial mucosa in lip repositioning for the correction of gummy smile.

CASE REPORT A 22-year-old healthy female patient presented to our hospital with a chief complaint of excessive display of gingiva when she smiles. She previously reported to a dentist with her complaint and was recommended orthodontic surgical intervention to correct her smile. However, she refused to undergo the procedure as she was apprehensive owing to the morbidity and the involvement of bone reduction associated with the procedure. She approached us and enquired about alternative options for the improvement of her smile. The patient’s medical history and family history were not significant. A systematic extra- and intra-oral examination was performed. Extraoral examination revealed a bilaterally symmetrical face. Her upper lip length was assessed by measurement from subnasale to the most inferior portion of the upper lip at the midline in the rest position and was 18 mm, considered to be short. She was diagnosed with a hyperactive upper lip, observed by a 10 mm lip rise when she smiles. Periodontal examination revealed probing depths within a range of 1–3 mm, and transgingival probing revealed alveolar crest at 2–3 mm distance apical to the cementoenamel junction. She displayed a moderate gingival display on smile extending from maxillary right second premolar to maxillary left second premolar. With a complete smile, there was an excess of 4–5 mm of gingival display (measured from the gingival margin) at the lateral incisor, canine, and premolar regions [Figure 1]. Gingival zenith and contour of her right maxillary central were slightly irregular. The anatomy of the anterior teeth with respect to crown height/width ratios was proportionate. Considering the patient’s preference for a less invasive procedure, we suggested a laser-assisted lip repositioning as

an alternate treatment option. A written informed consent was obtained after the patient was apprised of the surgical technique, safety aspects of the dental laser, possible complications associated with the procedure, and possibility of a relapse. Surgical procedure The treatment plan outlined was a laser-assisted lip repositioning surgery with gingival recontouring. Before the procedure, extraoral sepsis was carried out by swabbing with 5% povidone-iodine solution (Betadine, Win Medicare, India), and intraoral disinfection was performed with 10 ml of 0.2% chlorhexidine gluconate rinse (Hexidine 0.2%, ICPA, India). The surgical area was thoroughly anesthetized with a local anesthetic (2% lignocaine with 1:100,000 epinephrine). Laser safety protocols were strictly followed. Patient and the clinician were advised to put on the laser safety glasses specific to the wavelength of the laser. A diode laser (EZLASE, 940 nm, BIOLASE) was used for the procedure [Figure 2]. Initially, gingival recontouring was done to correct the gingival asymmetry of the maxillary right central incisor. A 400 μm fiber optic laser tip was used at an energy setting of 0.8W in continuous wave mode, with small paint brush-like strokes to ablate the marginal gingival tissue, to produce an ideal scalloping pattern of the gingiva. The height of the gingival contour was evaluated when the patient smiled and leftover remnants of ablated tissue were removed with sterile gauze soaked in saline. Going ahead with the laser-assisted lip repositioning procedure, as per the gingival display seen in the patient, the amount of excision of the mucosal strip should always be double the amount of gingival display that needs to be reduced. Following these guidelines, a 400 μm laser tip in a continuous mode at 0.8W was first used to demarcate the area to be scrapped in the surgical area [Figure 3]. The inferior border of the incision was outlined at the mucogingival junction and the superior border at about 10 mm (twice the gingival display) parallel to the lower border. Both these outlines were connected at the distal end of the second premolars. Laser ablation was carried at an energy setting of 1 W in a continuous mode, using light brush strokes to maintain the depth of ablation to scrape the epithelial mucosa and expose the underlying connective tissue [Figure 4]. Thermal relaxation to the tissue was given in between the procedure supplemented by the use of a high-speed suction device. After the entire mucosa demarcated between the outlined area was scraped (ablated), tissue tags were removed with sterile gauze soaked in saline and the area was irrigated with saline. The surgical area was evaluated, and the wound margins were approximated with multiple interrupted 3-0 Mersilk sutures (Ethicon) [Figure 5]. The patient was prescribed a mild analgesic (tablet ibuprofen 400 mg 3 times a day for 3 days) along with antibiotics (amoxicillin 500 mg 3 times a day for 5 days) postoperatively. The patient was given dietary instructions with intermittent ice pack application over the surgical area. She was advised to avoid activities such as talking and smiling that caused lip movement. The patient was recalled initially after a week for an evaluation and later after 2 weeks for suture removal. Healing

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Figure 2: Diode laser

Figure 1: Preoperative view displaying excess gingival display

Figure 3: Incision line demarcated with the fiber optic laser tip Figure 4: Laser-assisted ablation of the strip of mucosa

Figure 5: Multiple interrupted sutures given to approximate wound margins Figure 6: Postoperative view after suture removal

Figure 7: Gingival display after 1 month 166

Figure 8: Final postoperative view after 6 months with reduced gingival display Journal of Indian Society of Periodontology - Volume 21, Issue 2, March-April 2017

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Figure 9: Final postoperative view after 1 year with mild recurrence of gummy smile

was uneventful [Figure 6]. The patient was reevaluated after a month to assess the gingival display [Figure 7]. The patient was recalled after 6-month follow-up, and the results showed a marked reduction of gingival display [Figure 8]. The patient was quite satisfied and pleased with her smile. However, a follow-up visit after 1 year revealed a recurrence of her gummy smile, though not comparable to her excess gingival display at the baseline visit [Figure 9].

DISCUSSION The present case report describes the treatment of EGD with a novel laser-assisted lip repositioning surgical procedure. The results showcase patient’s satisfaction in the esthetic outcome of her smile. Literature is replete with numerous treatment modalities that have been used for the correction of EGD with conservative procedures such as esthetic crown lengthening, use of botulinum toxin, and lip repositioning to more invasive procedures such as myotomy or myectomy, rhinoplasty, and surgical correction associated with vertical maxillary excess.[5] Conventional lip repositioning in medical plastic surgery literature dates to 1983, when Miskinyar [5] described a technique of lip repositioning that involved myectomy and partial resection of the levator labii superioris muscles that permitted a satisfactory smile without any relapse. Ishida et al.[6] improvised the technique and reported a reduction in the gingival exposure of fourteen female patients treated for a hyperactive upper lip through myotomy of the levator labii superioris muscles with accompanying frenectomy. Although these procedures were successful in reduction of the EGD, they were demanding with resultant functional morbidity. A very recent novel technique introduced by Storrer et al.[7] was composed of a combination of containment surgery of the elevator muscle of upper lip and wing of nose along with gingival recontouring. Favorable outcomes were demonstrated with a 1-year follow-up, yet these patients had to undergo a long postoperative trauma period. To overcome these demanding surgical procedures and reduce the morbidity, botulinum toxin was introduced as a minimally invasive alternative to surgical lip repositioning. Polo[8] and Suber et al.[9] reported satisfactory results with the use of botulinum toxin, due to its ability to block the muscle activity. However, the transitory effect and frequent intramuscular injections forbid the extensive use of botulinum toxin in the correction of EGD.

The epitome of lip repositioning in dentistry was a case report by Rosenblatt and Simon.[4] Numerous reports of lip repositioning reported later in dental literature were adapted and altered from this clinical report[5-8] such as avoiding excision of labial frenum and esthetic crown lengthening accompanying lip repositioning.[10] The primary technique uniform to all these procedures was removing a strip of mucosa from maxillary buccal vestibule to shorten the vestibule and restrict the muscle pull to reduce the gingival display when the patient smiles. Most of these procedures resulted in complications such as severe discomfort, postoperative bruising, and damage to minor salivary glands resulting in mucocele formation.[11] However, the major drawback in an esthetic point of view was reports of recurrence of the gummy smile.[3] Taking into consideration these complications, we have used laser-assisted lip repositioning. Literature is abundant related to the successful application of diode lasers in soft-tissue surgery.[12] The primary advantages of laser application in soft-tissue surgery are relatively bloodless surgery with coagulation and reduced bacteremia with minimal discomfort postoperatively. [12] Bleeding associated with conventional lip repositioning procedures results in hematoma postoperatively, complicating the healing process. This serves as a reservoir for bacteria and tends to loosen the sutures in the initial healing period. Laser-assisted excision serves as an alternate option and provides immediate hemostasis thereby reducing the incidence of hematoma.[12] Furthermore, a bloodless surgical field enhanced relative ease of suturing which is pivotal to the success of the procedure. A major benefit of the laser in our case report was relatively less discomfort in the postoperative period. When compared with the scalpel there was reduced intraoperative bleeding and reduced bacteremia which can be attributed to sterile inflammatory condition.[13] An added advantage with the laser was high patient acceptability of the procedure due to its ease and less morbidity. However, a major limitation related to the surgical procedure is the recurrence of the gummy smile.

CONCLUSION Our case report demonstrated that laser-assisted lip repositioning surgery yielded promising results in the correction of gummy smile. The results revealed a marked reduction in gingival display at the 6-month follow-up. However, a mild recurrence was noticed in the follow-up period after 1 year. Literature is sparse related to the long-term follow-up of results obtained through laser-assisted lip repositioning. Yet, considering the ease of the procedure, excellent patient acceptability, and providing satisfactory treatment outcome, this can be considered as a novel feasible alternative in esthetic correction of gummy smile. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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