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| CASE REPORT |
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| Year : 2023 | Volume
: 15
| Issue : 1 | Page : 49-53 |
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Laser assisted modified lip repositioning surgery for the treatment of excessive gingival display using Y V plasty: A case report
Simran Ghumman, Devinder Singh Kalsi, Vikrant Sharma, Khushboo Arora, Ajit Jaiswal, Girish Chaudhary
Department of Periodontology and Implantology, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana, Punjab, India
| Date of Submission | 01-Dec-2021 |
| Date of Decision | 27-Mar-2022 |
| Date of Acceptance | 28-May-2022 |
| Date of Web Publication | 17-Feb-2023 |
Correspondence Address:
Simran Ghumman
43G Kitchlu Nagar, Ludhiana, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijds.ijds_150_21
Excessive gingival display is matter of concern for a lot of patients and affects their psychological well-being. Various methods have been employed to reduce excessive gingival display but with variable results. Modified Lip repositioning is a surgical way to correct gummy smile by limiting the retraction of the elevator smile muscles and yet preserve the labial frenum using Y-V plasty using a method that gives long term results along with being non-invasive and has high patient compliance. After thorough disinfection and achieving adequate anaesthesia, the strip of mucosa which had to ablated was marked with a laser, which was twice the amount of gingival display seen in the patient. After carrying out laser ablation of the marked tissue, and performing Y-V plasty, the surgical area was evaluated and the wound margins were approximated with multiple interrupted sutures. The patient was put on a regular follow-up. The results revealed a marked reduction in gingival display at the 3-month follow-up. Overall gingival display reduced from 6 mm to 2 mm.
Keywords: Diode laser, lip repositioning, Y-V plasty
How to cite this article:
Ghumman S, Kalsi DS, Sharma V, Arora K, Jaiswal A, Chaudhary G. Laser assisted modified lip repositioning surgery for the treatment of excessive gingival display using Y V plasty: A case report. Indian J Dent Sci 2023;15:49-53 |
How to cite this URL:
Ghumman S, Kalsi DS, Sharma V, Arora K, Jaiswal A, Chaudhary G. Laser assisted modified lip repositioning surgery for the treatment of excessive gingival display using Y V plasty: A case report. Indian J Dent Sci [serial online] 2023 [cited 2023 Mar 27];15:49-53. Available from: http://www.ijds.in/text.asp?2023/15/1/49/369892 |
| Introduction | |  |
In the past, dental treatment was mainly restricted to extraction and replacement of missing teeth, but advancements in the field of esthetic dentistry have expanded horizons of dental treatment. A pleasant smile is usually a balance between pink and white tissues, i.e., gingivae and teeth, and depends on factors such as degree of appearance of the gingiva, margins of both the lips, gingival health, and shape and size of teeth. Exposure of 1 mm of the gingiva apical to the lower border of the upper lip is considered normal and appears esthetically acceptable.[1] If this exposed gingiva is up to 2–3 mm, it can still be considered cosmetically acceptable; however, if it is more than 3 mm, it makes the smile appear gummy and therefore not very pleasant.[1],[2]
There are some established causes for excessive gingival display:[3] the first is due to altered passive eruption.[4],[5] In such patients, esthetic crown lengthening is done to restore normal dentogingival relationships. This is a well-established treatment option.[6],[7] The procedure involves soft and possibly hard tissue resection. The second etiology for excessive gingival display is compensatory eruption of upper teeth accompanied by migration of the attachment apparatus coronally. Although resective surgery is an option, it may expose the limited root surface, necessitating a restoration.[3],[4],[5] The third reason for gummy smile is vertical maxillary excess (VME), in which the vertical dimension of the midface is enlarged.[8] Treatment of such cases involves restoration of maxillomandibular relationships and reducing the display of the gingiva using orthognathic surgery;[9] this involves admission for days in a hospital and can have prominent postoperative discomfort for patients. The fourth reason is unrestrained apical movement of the upper lip due to retraction of the elevator smile muscles labially, thereby exposing teeth and causing a gummy smile.[3],[4],[5],[6],[9] For the treatment of such cases, surgical lip repositioning may be employed to improve the retraction of the smile muscles labially, thereby reducing gingival display. Plastic surgery journals first published this technique in 1973[10] and dental literature recently described it in 2006.[11]
Different treatment modalities have come up in the last few years with the objective of decreasing the appearance of gums. Various authors have attempted preventing muscles responsible for the movement of the upper lip, thereby reducing the display of the gingiva using Botox by inhibiting the contraction of the elevator smile muscles.[12],[13],[14],[15] Various authors have investigated increasing length of crown and, therefore, gingival display in individuals with altered passive eruption using esthetic crown lengthening.[16],[17] Some authors reduced upper lip mobility by removing a strip of mucosa from maxillary labial mucosa.[11],[18],[19] Myotomy was used by Ishida et al.[20] to segment the smile muscles of the upper lip and the maxillary frenulum, resulting inreduced movement of the lip when smiling. Ribeiro-Júnior et al.[21] recently published a new surgical technique meant to treat gummy smile, which was far more conservative in nature.[21] In their method, a modification of Rosenblatt and Simon technique,[3] the maxillary labial frenulum is preserved by removing two strips of mucosa bilaterally to the midline and suturing the mucosa apically. Silva et al.[22] showed an average reduction of 4.4 mm in gingival display using Rosenblatt and Simon's technique, and achieved satisfactory esthetics for the patients, in a series of their cases. A thorough case history is, therefore, required for accurate diagnosis to develop a good treatment plan to correct the deformity.
Lip repositioning works by reducing display of the gingiva by limiting action of elevator muscles. It is accomplished by removing mucosa between mucogingival junction and muscles of the upper lip in a strip form from the upper buccal vestibule followed by creation of a partial-thickness flap. Then, mucosa of the lip and mucogingival line are then sutured together, which results in a narrower vestibule and tightened pull of the elevator smile muscles, thereby reducing gingival display during smiling.[11]
Rubinstein and Kostianovsky[10] reported this procedure in cosmetic surgery literature to repair excessive gingival display produced by a hypermobile lip. This surgery was designed to be shorter, less aggressive with much lesser postoperative complications when compared to orthognathic surgery. Litton and Fournier[23] promoted this method for correction of gummy smile due to a short upper lip.
Contraindications for lip repositioning include presence of an inadequate attached gingiva zone which can lead to complications in flap design, stability, and suturing and severe VME.[3],[11] Thin gingival biotypes have shown increased possibility of relapse with the procedure.[3],[11] The amount of epithelium to be removed varies greatly depending on the surgical plan, and in the original report,[10] the amount of epithelium to be removed is not stated.
In one study,[24] a coronally advanced flap twice the display of the gingiva was advanced, thereby removing 10-12 mm epithelium in the process.[3],[11] Up to 20 mm of epithelium was removed in some cases.[25] Two most common postoperative symptoms include mild discomfort for a few days and a feeling of “tightness” upon smiling.[3] The surgery is considered safe, with very minor adverse effects such as postoperative bruising, pain, and inflammation of the lip following the surgery.[24]
Medical literature reports various surgical lip repositioning techniques. Several articles[26],[23],[25] advise excising smile muscle attachments to prevent smile muscles to revert back to its normal position and to reduce flap tautness during approximation of the tissue edges. Use an alloplastic or autogenous separator is also advised to prevent reattachment of elevator muscles.[27] This spacer is placed between the elevator smile muscles and anterior nasal spine via the nasal approach, thereby inhibiting upward movement of the repositioned lip. In the recent past, lip repositioning surgery has also been performed in combination with rhinoplasty.[28] Lip repositioning has also been combined with[29] frenectomy, crown lengthening[3] and depigmentation in a single visit. Lip repositioning can also be done with the use of a laser[30] as it was in the following case report.
Lip repositioning is often known to be associated with relapse and recurrence of gummy smile. Traditional lip repositioning has been well documented in the literature, but not many have performed modified lip repositioning surgery and none have described laser-assisted modified lip repositioning with Y-V plasty. This case report presents modified lip repositioning procedure for the treatment of gummy smile using laser with Y-V plasty.
| Case Report | | |
A 22-year-old female presented to the department of periodontology with a chief complaint of a gummy smile. There was no significant medical and family history that could contradict the surgical procedure. There was no facial asymmetry, and upon smiling, a rise of the upper lip was noted, which suggested that upper lip elevator muscles were hypermobile. Therefore, the patient was diagnosed as a case of increased gingival exposure along with hypermobility of the upper lip smile muscle. The patient was systemically and periodontally healthy, with balanced facial thirds and appropriate upper lip length, and 6 mm of the gingiva was present upon smiling. For calibration, display of the gingiva between the lower margin of the top lip and the marginal gingiva of the central incisor when light smiling was chosen to be a reference point [Figure 1]. Based on this, it was decided that a band of 12 mm would be marked and be ablated. After a thorough discussion of alternatives, side effects, and expected outcomes, written informed consent was obtained. The treatment plan was drawn which included laser-assisted modified lip repositioning surgery with Y-V plasty. The final treatment plan included lip repositioning surgery using laser with gingival recontouring.
Modified lip repositioning surgery
Before starting with the surgery, under aseptic conditions, anesthesia was administered to the operative area using 2% lignocaine HCl with 1:200,000 epinephrine. Protocols with respect to laser safety were religiously adhered to.
A diode laser (940 nm) was used. In this case, seeing the extent of the gingiva visible during smiling, it was decided that mucosa twice the amount of gingival display was required to be removed. Following the above-mentioned guidelines, a 400 μm laser tip in continuous mode at 0.8 W was utilized to first mark the surgical area, which was to be ablated [Figure 2]. The incision's lower border was marked at mucogingival junction, and the upper border was demarcated parallel to the lower border at roughly 12 mm (two times the gingival display). At distal end of the second premolars, both of these outlines were joined, forming an oval shape. The maxillary frenulum was preserved with Y-V plasty.
The mucosa was scraped and the connective tissue underneath the epithelium was exposed using laser ablation at a power of 1.2 W in a continuous mode with light strokes to maintain depth of ablated site [Figure 3]. In between procedures, the tissue was provided thermal relaxation, which was reinforced by use of a high-speed suction apparatus. After scraping (ablating) the entire mucosa that had previously been delineated, sterile gauze soaked in saline was used to remove extra tissue tags and then irrigated with saline solution.
Due to the presence of a prominent maxillary frenum, a Y-V plasty was performed. The frenum was detached from the underlying attached gingiva using a Y-shaped incision and was repositioned in the form of a V and sutured back together [Figure 4]. The frenum was preserved since it provides greater stability. The surgical wound was assessed, and several interrupted 3-0 silk sutures were used to approximate the wound edges [Figure 5].
Following the surgery, the patient was prescribed tablet ibuprofen 400 mg 3 times a day for 3 days as well as amoxicillin 500 mg 3 times a day for 5 days. Cold fomentation was prescribed and appropriate dietary instructions were given. After a week, the patient was called back for an examination and then again after 2 weeks for suture removal. Healing was uneventful. After a month, the patient was called back for a follow-up appointment to examine gingival display. The gingival display at 3-month follow-up was 2 mm [Figure 6]. The patient was pleased with her smile. | Figure 6: Follow up appointment at 3 months shows a gingival display of 2 mm
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| Discussion | | |
This case report describes a surgical method for treating excessive gingival exposure during smiling that differs from traditional lip repositioning surgery by Rubinstein and Kostianovsky in 1973,[10] after which this procedure has been refined several times. Correction of gummy smile in case of a short upper lip by detaching and repositioning the elevator smile muscles using lip repositioning surgery was described by Litton et al. in 1979. Miskinyar et al. in 1983 found no relapses in 27 patients that they treated for gummy smile with myectomy of either partial or complete excision of levator labii superioris muscles bilaterally.[25] In a study published in 2010, Ishida et al. observed that myotomy, dissection subperiostealy, and frenectomy greatly decreased gingival exposure in 14 patients. Although techniques such as orthognathic surgery, myectomies, and myotomies have been beneficial in reducing excessive gingival display, they are aggressive techniques that result in functional morbidity and postoperative discomfort. Vascular injuries, nerve exposure, and damage are among the many possible postoperative problems that have been recorded following such procedures. Soft tissue injuries, dyspnea, hematoma, hemorrhage, and paresthesia are some other commonly reported postoperative complications.[31]
Storrer et al. developed a procedure that included gingival recontouring and contained the musculature of the top lip and wing of the nose. A 1-year follow-up revealed favorable results, despite the fact that their patients had a lengthy postoperative period.[32]
Botox is a minimally invasive alternative to lip repositioning surgery which when used for the management of gummy smile, has decreased morbidity with fewer postoperative complications. Polo[11] published positive results with Botox, because of its transient nature and its capability to block muscle function. However, because of its transient nature, botulinum toxin cannot be used extensively to treat esophagogastroduodenoscopy.
The majority of such treatments lead to postoperative problems such as discomfort, hematoma formation, and mucocele formation because of damage to small salivary glands. However, recurrence of excessive gingival display was a major drawback. To avoid these concerns, laser-assisted lip repositioning was performed in this case.
Maxillary labial frenum is not severed in modified lip repositioning surgery. The fundamental goal of retaining the upper frenulum is to prevent midline from shifting, resulting in an esthetically pleasant smile, as well as to avoid morbidity associated with its removal.
The key benefits of using a laser in lip repositioning surgery are a relatively bloodless procedure with coagulation, as well as low postoperative discomfort. It is to be noted that rather than surgically removing a strip of mucosa in this case, tissue was ablated using laser. This was done because laser causes reduced bleeding at surgical site and patients suffer lesser postoperative discomfort. In our case report, one of the significant advantages of laser was reduced postoperative discomfort. Due to its simplicity and low morbidity, this laser technique has high patient acceptability. Relapse after lip repositioning surgery has been described in previous studies.[10],[21],[25],[33],[34] The presence of a thin biotype is a significant predisposing factor for recurrence.[25],[33] All these factors when taken into account make laser-assisted modified lip repositioning with Y-V plasty an excellent choice for surgical management of excessive gingival display and for providing relatively long-term results and high patient acceptability.
| Conclusion | | |
The combination of laser-assisted modified lip repositioning surgery and Y-V plasty of maxillary frenum has shown encouraging results for repair of excessive gingival display in this case report. At the follow-up visit after 3 months, the results demonstrated a significant decrease in gingival display. Overall gingival display reduced from 6 mm to 2 mm. The literature on long-term effects of lip repositioning surgery with laser is limited. However, given this procedure's simplicity, high acceptability by patients, and positive outcomes, this can be considered a novel viable alternative in the esthetic correction of gummy smiles.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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