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Excessive Gingival Display Managed with Surgical Lip Repositioning, Esthetic Crown Lengthening, and Veneers

by Kenneth Valladares, DDS, CDT, & Paula Vargas, DDS, MBA

Excessive gingival display, also referred to as gummy smile, can be managed by a variety of treatment modalities, depending on the etiology. Mild and moderate gummy smiles can be successfully treated by periodontal plastic surgery. However, for excessive gingival display as in vertical maxillary excess (VME) II or III cases with 5 to 8 mm or more of gingival exposure, this procedure is not enough. Many patients decline the more invasive Le Fort surgery and opt for a less invasive surgical lip-repositioning procedure. Therefore, surgical lip repositioning combined with crown lengthening is suggested as an effective and predictable procedure to reduce gingival display.

Etiologies of Excessive Gingival Display:

A gummy smile may be caused by a number of factors. Common etiologies include altered passive eruption (APE), vertical maxillary excess (VME), hypermobile upper lip (HUL), and short upper lip (SUL). Other etiologies include short clinical crowns, dentoalveolar extrusion, and gingival overgrowth.

Examples of different factors, or combinations of them, causing a gummy smile. a) VME III. b-d) Dentoalveolar extrusion. e) SUL. f) Hereditary gingival fibromatosis. g) Altered passive eruption. h, i) Dentoalveolar extrusion due to protrusive bruxism.

Case Report:

A 20-year-old female presented to the authors’ practice concerned about her gummy smile and the shape of her teeth. She stated that she avoided smiling due to the appearance of her teeth and excessive gingival display, which averaged approximately 7 mm.

The facial analysis determined the patient had well-proportioned facial thirds. Therefore the etiology of her gummy smile apparently was not skeletal and she did not have VME. Upon examination, the cephalometric diagnosis indicated Class I, Type I and APE type 2A, corroborating the absence of VME. The patient also displayed a regular lip length and HUL.

A combination of surgical lip repositioning with periodontal plastic surgery for pink esthetics was planned to reduce the patient’s excessive gingival display. The placement of veneers from teeth #4 to #13 was also planned to rectify anterior white esthetics and to improve the shape, proportion, and position of the teeth since she declined any other treatment option. It was decided to perform indirect composite veneers due to the excellent esthetic results and longevity of contemporary nanocomposites.

"…failing to take soft tissue considerations into account will negate all the other aspects of treatment, resulting in ultimate esthetic failure.”

Lip-repositioning:

The lip-repositioning procedure began by anesthetizing the affected area. As in the conventional technique, a partial thickness incision was made along the mucogingival junction. A second parallel incision was made at the labial mucosa approximately 10 to 12 mm from the first incision. The two incisions were connected at the mesial line angles of the maxillary first molars to create an elliptical outline. In most cases, including this one, it is preferred to preserve the frenum in order to maintain proper alignment of the lip midline with the dental midline. The epithelium was removed from the incision outline, leaving the muscle fibers exposed. The fibers were bundled every 5 to 7 mm with synthetic, braided sutures (4-0 Vicryl), and the bundles sutured to the periosteum. Work with the upper lip levator is done without touching other muscles, such as the buccinator and orbicularis oris, because the goal is to limit the lifting of the lip, but not affect the rest of its mobility. Finally, the edges of the initial incision were sutured with the 4-0 Vicryl.

Elliptical partial thickness incision of the labial mucosa.

Muscle fibers bundled every 5 to 7 mm and sutured to the periosteum.

Edges of the initial incision sutured with 4-0 vicryl.

Retracted view 10 days after the procedure.

Full-smile view three weeks after the procedure.

Gingivectomy:

The procedure was performed four weeks after surgical lip repositioning. After anesthetizing the area, a surgical guide was created. With the tip of an explorer, reference marks were made to indicate the zenith points of the new gingival contour, being careful to preserve as much of the existing keratinized tissue as possible. Beveled incisions were used to create the new gingival edge. Clean cuts were made while creating a suitable architecture for the new gingival contour. Recontouring was done with a new scalpel blade.

To ensure efficient cutting with clean edges, the blade was replaced with a new one after three pieces of tissue were cut. After completing the incisions, the gingival tissue was removed using intrasulcular incisions to sever the junctional epithelium and connective tissue if necessary.

Reference marks indicate the zenith points of the new gingival contour.

Beveled incisions create the new gingival edge.

Recontouring:

With the gingivectomy complete, the new shape and height of the gingival contour were used to prepare margins that would serve a double purpose: they would not only serve as the final preparation margins for the veneers, but also as a reference for the recontouring and osteoplasty of the alveolar bone crest, which must be performed immediately. These margins are of vital importance because they serve as a guide for maintaining the biological width. After the margins were prepared, the gingival flap was lifted to proceed with the osteoplasty. Recontouring of the crestal bone was carried out maintaining the crestal bone margin at a 3-mm distance from the prepared margins, reestablishing the biologic width. It is important to recreate an adequate architecture, shape, and volume of the crestal bone, as this ensures long-term marginal stability. By respecting the biologic width, gingival tissue growth or recession can be prevented. The new bone contour was remeasured to ensure that a distance of 3 mm was maintained after osteoplasty. This measurement must be taken radially, placing the probe over the center of the tooth and rotating the probe over this axis and the new edges. Probes calibrated to 3-mm intervals were used to make the measuring easier and eliminate the risk of error. The procedure was completed with repositioning and suturing of the mucoperiosteal flap with 4-0 Vicryl.

Margins are prepared that will serve as a reference for osteoplasty.

The gingival flap is lifted in order to proceed with the osteoplasty.

Recontouring of the crestal bone is carried out to reestablish the biologic width.

Remeasuring ensures that the biologic width has been properly reestablished.

Repositioning and suturing of the mucoperiosteal flap with 4-0 vicryl.

Retracted view of the completed procedure.

Preparation and Impression:

An anatomical wax-up was performed on a cast, and a matrix was created to make a mock-up to obtain the needed space for the veneers and achieve the most conservative enamel preparation. Tooth preparation was followed by using a round-end tapered coarse diamond bur. In this case this work was done almost entirely on the mock-up material, then the excess was removed and the margins were prepared creating rounded shoulders.

Sharp corners and line angles were rounded using a round-end tapered diamond fine bur, followed by an ultra-fine grit diamond to smooth out the preparations. The double-cord technique was performed using two plain knitted retraction cords.

Anatomical wax-up performed on a cast to create a matrix and make a mock-up.

Conservative preparations on the mock-up.

Conservative preparations on the mock-up.

Smoothing out the preparations with an ultra-fine grit diamond.

Double-cord technique using two plain knitted retraction cords.

Impression using heavy-body and lightbody normal-set PVS impression material.

Veneers completed and placed on the model to test fit and function.

Preoperative full-face view.

Postoperative full-face view.

Two-year follow-up showing the stability of the results.

This article originally appeared in the Journal of Cosmetic Dentistry, Volume 24, Issue 2. Read more here.

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