CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY Surgical Treatment of Excessive Gingival Display Using Lip Repositioning Technique and Laser Gingivectomy as an Alternative to Orthognathic Surgery Dragana Gabric Panduric, PhD, DMD, * Marko Bla skovic, DMD,y Juraj Brozovic, DMD,z and Mato Susi c, PhD, DMDx Excessive gingival display (EGD) is a condition in which an overexposure of the maxillary gingiva (>3 mm) is present during smiling. The proper diagnosis and determination of its etiology are essential for the se- lection of the right treatment modality. Different techniques have been used in cases of hyperactive upper lip: botulinum toxin injections, lip elongations with rhinoplasties, lip muscle detachments, myotomies, and lip repositions. This report presents a case of a young woman with an EGD larger than 10 mm during smiling caused by altered passive eruption, vertical maxillary excess, and a hyperactive upper lip that was treated with a modified lip repositioning technique and laser gingivectomy because she strongly refused orthognathic surgical treatment. A novel addition to the technique is proposed, a reversible trial accom- plished just by applying sutures on the borders of the future split-thickness flap, marked using diode laser, before starting the flap incision. Ó 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:e1-e11, 2013 Excessive gingival display (EGD), commonly termed gummy smile, is a condition in which there is an over- exposure of the maxillary gingiva during smiling; in se- vere cases, the overexposure is present in repositioning of the mouth and lips. 1 Although some gingival display gives the impression of a youthful smile, a gingival display larger than 3 mm is considered unattractive. 2 According to different investigators, a gummy smile is considered a gingival display from 2 to 3 mm when smil- ing. 3,4 It can affect about 10.5% of the population, 5 with a female predominance (2:1) and affecting persons 20 to 30 years of age. 6 The incidence of this condition de- creases with age as a result of dropping of the upper and lower lips. 2 The etiology of EGD is various: plaque- or drug- induced gingival enlargement, altered or delayed passive eruption, anterior dentoalveolar extrusion, vertical maxillary excess, short upper lip, a hyperac- tive upper lip, or a combination of these causes. Proper diagnosis of the etiologic factor is essential for the selection of the right treatment protocol. Pla- que- or drug-induced gingival enlargement and altered or delayed passive eruption are treated with peri- odontal surgery. Depending on the classification of the latter, bone surgery also may be required. Anterior dentoalveolar extrusion is treated with orthodontic intrusion and vertical maxillary excess is treated with orthognathic surgery. 7 In the literature, different techniques have been reported for the treatment of the hyperactive upper lip: injections of botulinum toxin, 8 lip elongation associated with rhinoplasty, 9 detachment of lip muscles, 10 myotomy and partial removal, 11,12 and lip repositioning. 13-15 The lip repositioning technique was first described 1973 by Rubenstein and Kostianovsky 16 as part of medical plastic surgery. Later on, it was introduced *Assistant, Department of Oral Surgery, School of Dental Medicine, University of Zagreb, Zagreb, Croatia. yPrivate Dental Clinic, Rijeka, Croatia. zPrivate Dental Office, Split, Croatia. xProfessor, Department of Oral Surgery, School of Dental Medicine, University of Zagreb, Zagreb, Croatia. Address correspondence and reprint requests to Dr Gabric Pan- duric: Department of Oral Surgery, School of Dental Medicine, Uni- versity of Zagreb, Gunduliceva 5, 10000 Zagreb, Croatia; e-mail: [email protected]Received September 23 2013 Accepted October 23 2013 Ó 2013 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/01328-1$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.10.016 e1
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CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
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Surgical Treatment of Excessive GingivalDisplay Using Lip Repositioning Techniqueand Laser Gingivectomy as an Alternative
to Orthognathic Surgery
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yPrivatezPrivatexProfesdicine,
Addres
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Dragana Gabri�c Panduri�c, PhD, DMD,* Marko Bla�skovi�c, DMD,yJuraj Brozovi�c, DMD,z and Mato Su�si�c, PhD, DMDx
Excessive gingival display (EGD) is a condition in which an overexposure of the maxillary gingiva (>3 mm)
is present during smiling. The proper diagnosis and determination of its etiology are essential for the se-
lection of the right treatment modality. Different techniques have been used in cases of hyperactive upper
and lip repositions. This report presents a case of a young woman with an EGD larger than 10 mm duringsmiling caused by altered passive eruption, vertical maxillary excess, and a hyperactive upper lip that was
treated with a modified lip repositioning technique and laser gingivectomy because she strongly refused
orthognathic surgical treatment. A novel addition to the technique is proposed, a reversible trial accom-
plished just by applying sutures on the borders of the future split-thickness flap, marked using diode laser,
before starting the flap incision.
� 2013 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:e1-e11, 2013
Excessive gingival display (EGD), commonly termed
gummy smile, is a condition in which there is an over-exposure of the maxillary gingiva during smiling; in se-
vere cases, the overexposure is present in repositioning
of the mouth and lips.1 Although some gingival display
gives the impression of a youthful smile, a gingival
display larger than 3 mm is considered unattractive.2
According to different investigators, a gummy smile is
considered a gingival display from2 to 3mmwhen smil-
ing.3,4 It can affect about 10.5% of the population,5 witha female predominance (2:1) and affecting persons 20
to 30 years of age.6 The incidence of this condition de-
creaseswith age as a result of droppingof the upper and
7. Silberberg N, Goldstein M, Smidt A: Excessive gingival display—Etiology, diagnosis, and treatment modalities. Quintessence Int40:809, 2009
8. Polo M: Botulinum toxin type A in the treatment of excessivegingival display. Am J Orthod Dentofacial Orthop 127:214, 2005
9. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, et al: New approachto the gummy smile. Plast Reconstr Surg 104:1143, 1999
10. Litton C, Fournier P: Simple surgical correction of the gummysmile. Plast Reconstr Surg 63:372, 1979
11. Miskinyar SA: A newmethod for correcting a gummy smile. PlastReconstr Surg 72:397, 1983
12. Ishida LH, Ishida LC, Ishida J, et al: Myotomy of the levator labiisuperioris muscle and lip repositioning: A combined approach
for the correction of gummy smile. Plast Reconstr Surg 126:1014, 2010
13. Rosenblatt A, Simon Z: Lip repositioning for reduction of exces-sive gingival display: A clinical report. Int J Periodontics Restor-ative Dent 26:433, 2006
14. Silva CO, Ribeiro-J�unior NV, Campos TV, et al: Excessive gingivaldisplay: Treatment by a modified lip repositioning technique.J Clin Periodontol 40:260, 2013
15. Ribeiro-J�unior NV, Campos TV, Rodrigues JG, et al: Treatmentof excessive gingival display using a modified lip reposition-ing technique. Int J Periodontics Restorative Dent 33:309,2013
16. Rubenstein A, Kostianovsky A: Cosmetic surgery for the malfor-mation of the laugh: Original technique. Prensa Med Argent 60:952, 1973
17. Jacobs PJ, Jacobs BP: Lip repositioning with reversible trial forthe management of excessive gingival display: A case series.Int J Periodontics Restorative Dent 33:169, 2013
18. Ellenbogen R, Swara N: The improvement of the gummy smileusing the implant spacer technique. Ann Plast Surg 12:16,1984
19. Humayun N, Kolhatkar S, Souiyas J, et al: Mucosal coronallypositioned flap for the management of excessive gingivaldisplay in the presence of hypermobility of the upper lipand vertical maxillary excess: A case report. J Periodontol81:1858, 2010
20. Polo M: Botulinum toxin type A (Botox) for the neuromuscularcorrection of excessive gingival display on smiling (gummysmile). Am J Orthod Dentofacial Orthop 133:195, 2008