Title	Modified Lip Repositioning Surgery for the Management of Excessive Gingival Display Caused by Hyperactive Upper Lip Is a Viable Treatment Option
Clinical Question	Should lip repositioning surgery be part of our armamentarium for the management of excessive gingival display?
Clinical Bottom Line	The modified lip repositioning surgery should be considered alone or as an adjunctive procedure for the management of “gummy smile.” This technique, although based on lower level evidence, has proven successful in cases with a hyperactive upper lip etiology in providing an esthetically satisfactory reduction of the gingival display while being minimally invasive and having limited complications. A thorough patient evaluation, an understanding of the etiology and treatment options for the management of “gummy smile,” and an informed consent that reflects the likely elective nature of treatment and the lack of longitudinal studies on the stability of outcome are all prerequisites to treatment.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 23278672 Silva/2013 13 patients Case series Key results The patients in this report had excessive gingival display primarily associated with a hyperactive upper lip. The baseline gingival display was 5.2 ± 1.4 mm, and it was reduced to 1.91 ± 1.50 mm at 6 months (p-value < 0.0001) postoperatively. Using a stringent 1-mm gingival display during smile as a criterion of clinical success, 77% success was observed at 6 months. A strong correlation was identified between the resulting minimized gingival display and the combination of upper lip and vermillion length changes. Minimal complications were reported; 92% of patients suffered frequent pulling sensation in the first week post-op and some also experienced transient numbness. Based on a survey 2.5 years following surgery: 70% of the patients were satisfied with their smile displaying the “about right” amount of gingiva with 92% willing to undergo the procedure again based on overall experience. 23484172 Jacobs/2013 7 patients Case series Key results The patients in this report had excessive gingival display associated with a hypermobile upper lip alone or in combination with other etiology. The mean gingival display at baseline was 5.3 ± 1.5 mm measured at the central incisors. The mean reduction in the gingival display was 6.4 ± 1.5 mm (unclear timeline of 1 month to 3 years’ post-surgery), voluntarily placing the inferior portion of the upper lip below the central incisors’ zenith to compensate for possible relapse. Six of 7 patients were satisfied by the outcome, the last patient having remorse about opting for less reduction than advised.
Evidence Search	("lip"[MeSH Terms] OR "lip"[All Fields]) AND ((((("lip"[MeSH Terms] OR "lip"[All Fields] OR "lips"[All Fields]) AND ("gingiva"[MeSH Terms] OR "gingiva"[All Fields])) AND ((((("lip"[MeSH Terms] OR "lip"[All Fields]) AND ("surgery"[Subheading] OR "surgery"[All Fields] OR "surgical procedures, operative"[MeSH Terms] OR ("surgical"[All Fields] AND "procedures"[All Fields] AND "operative"[All Fields]) OR "operative surgical procedures"[All Fields] OR "surgery"[All Fields] OR "general surgery"[MeSH Terms] OR ("general"[All Fields] AND "surgery"[All Fields]) OR "general surgery"[All Fields])) NOT ("crown lengthening"[MeSH Terms] OR ("crown"[All Fields] AND "lengthening"[All Fields]) OR "crown lengthening"[All Fields])) NOT ("onabotulinumtoxinA"[Supplementary Concept] OR "onabotulinumtoxinA"[All Fields] OR "botox"[All Fields])) OR (periodontal[All Fields] AND ("surgery, plastic"[MeSH Terms] OR ("surgery"[All Fields] AND "plastic"[All Fields]) OR "plastic surgery"[All Fields] OR ("plastic"[All Fields] AND "surgery"[All Fields]))))) AND ((excessive[All Fields] AND ("gingiva"[MeSH Terms] OR "gingiva"[All Fields] OR "gingival"[All Fields]) AND display[All Fields]) OR (gummy[All Fields] AND ("smiling"[MeSH Terms] OR "smiling"[All Fields] OR "smile"[All Fields])))) AND (("lip"[MeSH Terms] OR "lip"[All Fields]) AND repositioning[All Fields]))
Comments on The Evidence	VALIDITY: The evidence presented is low level, and it would be beneficial to pursue further knowledge through longitudinal studies with larger samples as well as studies that direct compare this technique to other treatment modalities, for example, injections of botulinum toxin type A. Only Silva/2013 mentioned reliability assessment (one experienced and calibrated periodontist with a coefficient of variation of ≤ 3%) and included a statistical analysis of the data gathered. The evidence presented looked at one particular modification to the lip repositioning technique, mucosa stripes removed without midline maxillary labial frenectomy. The bulk of evidence available at this time through case reports and case series is heavily skewed towards young women, which is representative of the female prevalence as well as the population who would likely seek such esthetic treatment. The evidence above is based almost exclusively on females, who presented with, in the majority of cases, a single etiology for excessive gingival display; hyperactive upper lip. The modified lip repositioning technique has also been presented in the literature in cases with more complex etiology as an adjunct following or with other procedures (3/7 patients in the second study presented). Both studies above had a 100% compliance rate but have a limited sample size and follow-up with clinical parameters assessed and measured post-surgery only short-term. PERSPECTIVE: Considering factors mentioned above, although limited evidence is available to support this clinical procedure, given a rigorous case selection and solid informed consent, I would still consider it as an option. Since it is an elective procedure (which could be reversed by vestibular extension procedure if absolutely necessary), completing a reversible trial procedure as described in the second article prior to proceeding to the definitive surgery could be a valuable tool. Furthermore, Ribeiro-Junior et al. 2013 (PMID: 23593624) presented several interesting technical pearls of wisdom in their article.
Applicability	This technique requires minimal instrumentation that is likely to be available in most dental clinics. Proper documentation of the case with clinical photographs is highly recommended. According to presented evidence, it applies to patients presenting with a chief complaint of “gummy smile” associated with a fairly limited and specific etiology. Systemic conditions or medications should be noncontributory to the condition and the patient should have a healthy periodontium. As mentioned by Silva et al., a narrow band of attached gingiva at baseline will likely lead to significant technical difficulties and render too much reduction in the vestibule, hindering patient’s oral hygiene, and therefore should be avoided. Discomfort in the days following surgery is expected with possible temporary complications such as numbness and pulling sensation. The patient should be advised that a scar line, non-apparent during a smile, will likely remain at the surgical site and that long-term stability has not been evaluated; therefore relapse is a plausible outcome.
Specialty	(General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords	Lip repositioning surgery, excessive gingival display
ID#	3278
Date of submission	11/07/2017
E-mail	belanger@livemail.uthscsa.edu
Author	Lizandre Belanger, DMD
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Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available