The International Journal of Periodontics & Restorative Dentistry

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 309

Treatment of Excessive Gingival Display

Using a Modified Lip
Repositioning Technique

Excessive gingival display is an es-

Noé Vital Ribeiro-Júnior, DDS, MSc1 thetic concern for patients. The
Thiago Veiga de Souza Campos, DDS2 smile is one of the key factors of a
Jefferson Guilherme Rodrigues, DDS2 first impression.1 The essential ele-
Thiago Modolo Azevedo Martins, DDS, MSc3 ments of a pleasant smile include
Cléverson O. Silva, DDS, MSc, PhD4 the lips, teeth, and gingival scaf-
fold.2 Lips define the esthetic zone
and, while smiling, liplines have
Excessive gingival display during smiling (“gummy smile”) is an esthetic
issue that affects a considerable part of the population. The hyperactivity of been defined as low, medium, or
the elevator muscle of the upper lip is one of the main causes of a gummy high.1 The lipline is considered low
smile, and several techniques have been proposed for its treatment. The aim when only part of the teeth are vis-
of this report is to describe a modification of the lip repositioning technique ible below the upper lip, medium
to achieve stable and significant outcomes through a more conservative
when 1 to 3 mm of the marginal gin-
procedure. Two patients complaining about a gummy smile were treated with
gival is exposed during a smile, and
the proposed technique and presented, after a 6-month follow-up, significant
improvement in the amount of gingival exposure and esthetic satisfaction. (Int high (ie, a gummy smile) when more
J Periodontics Restorative Dent 2013;33:309–315. doi: 10.11607/prd.1325) than 3 mm of gingiva is shown.1,2
Tjan et al1 observed that 20.5%
of the population presented a low
lipline, 69% medium, and 10.5%
high. Peck et al3 found a correla-
tion between gender and the type
of smile, with a predominance of
gummy smiles in females (2:1) and
of low liplines in males (2.5:1).
Excessive gingival display is as-
1Professor, Department of Clinic and Surgery, School of Dentistry, Alfenas Federal
University (Unifal-MG), Alfenas, Minas Gerais, Brazil. sociated with different etiologies,
2Graduate student, Department of Clinic and Surgery, School of Dentistry, Alfenas Federal
such as altered passive eruption,
University (Unifal-MG), Alfenas, Minas Gerais, Brazil. anterior dentoalveolar extrusion,
3Graduate student, State University of Maringá (UEM), Maringá, Paraná, Brazil.

4Professor, School of Dentistry, Ingá University (UNINGÁ)/State University of Maringá vertical maxillary excess, short and
(UEM), Maringá, Paraná, Brazil. hyperactive upper lip, or a com-
bination of these causes.2,4 Iden-
Correspondence to: Dr Cléverson O. Silva, Av. Colombo, 9727, Km 130, CEP: 87070-810
tification of the correct etiology is
Maringá, PR, Brazil; fax: +55 44 3033-5009; email: prof.cleversonsilva@gmail.com.
essential for the establishment of
©2013 by Quintessence Publishing Co Inc. an adequate treatment plan.

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310
Altered passive eruption re-
quires periodontal surgery that in-
cludes gingivectomy or an apically
repositioned flap associated with
or without osseous resection.4–7
Dentoalveolar extrusion is usu-
ally treated with orthodontic intru-
sion and vertical maxillary excess
with orthognathic surgery.2,4,8–11 For
treatment of gummy smile due to
hyperactive upper lip, variable out-
comes have been reported with
the use of different techniques,
such as botulinum toxin injec-
tion,12,13 lip elongation associated
with rhinoplasty,14 detachment of
lip muscles,15 myectomy and partial
removal,16 and lip repositioning.17,18
The lip repositioning tech-
nique was initially used in medical
plastic surgery17 and more recently
in dentistry.18–20 This procedure is
accomplished by removing a strip
of mucosa from the maxillary buc-
cal vestibule and suturing the lip
mucosa to the mucogingival line.
The aim of this case report is
to present a modification of the
technique used by Rubinstein and
Kostianovsky17 and Rosenblatt and
Simon18 that provides good out-
comes and patient satisfaction.
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Fig 1    Patient no. 1; note the excessive gingival display.
Case reports
Patient no. 1
A 22-year-old woman presented
to the Clinic of Periodontics at the
Alfenas Federal University, Alfenas,
Brazil, for an esthetic evaluation
of her smile. The patient reported
dissatisfaction with the amount of
gingiva exposed while smiling. Her
aim was to obtain a “natural and
harmonious” smile. Her medical
history revealed systemic health
and no medication intake. During
clinical evaluation, it was verified
that 7 mm of gingiva was displayed
during her smile, showing harmoni-
ous and healthy gingiva and nor-
mal upper lip length (Fig 1). The
clinical length of the central inci-
sor was 11 mm, with the cemento­
enamel junction (CEJ) in normal
relation to the gingival margin
(1 mm subgingival), and there was
no vertical maxillary excess or dento­
alveolar extrusion. During smiling,
there was 12 mm of lip rising. These
observations led to a diagnosis of
hyperactive upper lip. Consequent-
ly, a lip repositioning technique,
modified from Rosenblatt and
Simon,18 was planned for treatment
of her gummy smile.
One hour prior to surgery, the
patient was given 750 mg acet-
aminophen (Cilag Farmacêutica)
for pain management. Extraoral an-
tisepsis was performed with 2.0%
chlorhexidine solution (Farmácia
Escola) and intraoral with 0.12%
chlorhexidine (Farmácia Escola)
rinse for 1 minute. Local infiltration
with lidocaine 2.0% with 1:100.000
epinephrine (Alphacaina, Adrenali-
na 1:100.000, DFL Ind E Com) was
used for anesthesia.
The surgical procedure was
initiated at one side of the maxilla
with a partial-thickness horizontal
incision 1 mm coronal to the muco­
gingival line from the midline until
the first molar region. Two verti-
cal incisions at the extremities of
the first incision, extending 10 to
12 mm apically, were made. Fi-
nally, a horizontal incision, parallel
to the first, connecting the vertical
incisions was made (Fig 2). The epi-
thelium was removed, leaving the
connective tissue exposed (Fig 3).
Minor salivary glands were removed,
when necessary. Continuous in-
terlocking sutures (Poligalactina
 311

Fig 2    Incisions made for mucosa removal. Fig 3    Epithelium removed and connective tissue exposed on the
right side.

Fig 4    Mucosa coronally positioned and sutured at the right side Fig 5    Both sides sutured.
and epithelium removed from the left side; note that the maxillary
frenum was kept intact.

Fig 6    Patient no. 1 at 6-month follow-up.

4/0) were used to stabilize the
mucosa to the gingiva, and the
procedure was repeated on the
contralateral side, leaving the mid-
line frenum intact (Figs 4 and 5).
Postoperative prescriptions
included analgesics (acetamino-
phen 750 mg four times per day
for 2 days) and antimicrobial rinse
(0.12% chlorhexidine rinse twice
daily for 1 week). Postoperative
instructions included application
of ice pack, a soft food diet dur-
ing the first week, avoidance of any
mechanical trauma to the surgical
site, and restriction of lip move-
ment (smiling or talking) during the
first 2 weeks.
Postoperative healing was un-
eventful. The patient complained
about tension on talking and smil-
ing, lasting about 1 week. A minor
scar formed on the suture lines, but
remained invisible during smiling.
The 6-month follow-up showed
a reduction of gingival display, with
only 1 mm of gingiva visible during
the smile (Fig 6). The patient was
satisfied with her more natural and
harmonious smile.

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312

Fig 7    Patient no. 2; note the excessive gingival display. Fig 8    Profile showing the amount of lip rising during smiling.

Fig 9    Mucosa suture at both sides of midline frenum. Fig 10    Gingivectomy performed.

Fig 11    Patient no. 2 at 6-month follow-up.

Patient no. 2
A 20-year-old woman presented
to the Clinic of Periodontics at the
Alfenas Federal University, Alfenas,
Brazil, complaining about her gum-
my smile. During clinical evaluation,
it was verified that 6 mm of gingiva
was displayed during her smile, with
healthy gingiva and normal upper
lip length (Fig 7). Tooth evaluation
revealed short and square clinical
crowns in the maxillary anterior re-
gion, and probing demonstrated
the alveolar bone crest being lo-
calized 2 mm apically to the CEJ,
leading to the diagnosis of altered
passive eruption (type 1A). Eleven
mm of lip rising was observed dur-
ing smiling, which led to the diagno-
sis of hyperactive upper lip (Fig 8).
There was no vertical maxillary ex-
cess or dentoalveolar extrusion.
The final diagnosis was excessive
gingival display due to a combina-
tion of altered passive eruption and
hyperactive upper lip. The treat-
ment plan included a modified lip
repositioning technique and con-
comitant gingivectomy.

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A lip repositioning procedure
was performed, same as for patient
no. 1 (Fig 9), and gingivectomy was
performed following suturing for
the lip repositioning (Fig 10). Heal-
ing was uneventful, and 6 months
after treatment the patient exhib-
ited a harmonious smile with a me-
dium lipline (Fig 11).
Discussion
This report aimed to document a
modified lip repositioning tech-
nique to decrease the amount of
gingival display in patients with hy-
peractivity of the upper lip elevator
muscle. The results of the clinical
cases show esthetic satisfaction af-
ter 6 months of follow-up.
The technique described is a
modification of the original tech-
nique by Rubinstein and Kosti-
anovsky,17 initially used in medical
plastic surgery and adapted for use
in dentistry.18–20 In the modifica-
tion employed here, the maxillary
labial frenum was maintained and
two mucosal strips, one at each
side of the frenum, were removed.
This modification was introduced
to maintain the labial midline and
reduce postoperative morbidity.
The amount of tissue re-
moved, 10 to 12 mm, was the
same in both cases, as proposed
by other authors.18,19 However,
the extent of upper lip mobility
reduction is variable and not pre-
dictable. In the first case, 6 mm
of lip movement reduction was
achieved, and in the second case,
only 4 mm. Similar outcomes
were reported by Rosenblatt and
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Simon18 and Humayun et al,20
who achieved approximately 4 mm
of gummy smile reduction. There-
fore, at this point no correlation
can be established between the
amount of tissue removed and the
amount of reduction in lip move-
ment.
An asymmetric effect on re-
duction of lip movement is a pos-
sibility, but did not occur in this
study. There are ways to ensure a
symmetric outcome, such as main-
tenance of the lip frenum, which
facilitates repositioning of the la-
bial midline; removal of the same
amount of tissue on both sides of
the frenum; and removal of both
strips of mucosa before suturing,
which allows comparison of the
two sides.
The first step in obtaining suc-
cess in any treatment is a correct
diagnosis. To determine that other
causes are not associated with the
hyperfunction of the upper lip el-
evator muscle, certain features
should be observed. Facial propor-
tions must be normal with symme-
try in the three horizontal thirds,
without identification of higher
proportion of the inferior third,
which could characterize an exces-
sive maxillary vertical growth.23 The
normal lip length, which averages
between 20 and 24 mm, must be
considered.24 Another feature to
be evaluated is the distance be-
tween the gingival margin and
CEJ, which ideally is ≤ 1.5 mm.25
Distances greater than 1.5 mm in-
dicate an excessive gingival tissue
covering the tooth crown, typical
in altered passive eruption. Finally,
the crown length–height relation
313
must be evaluated. The “gold
standard” esthetic proportion de-
termines that the maxillary central
incisor’s width must be about 80%
of its length, with an accepted
variation between 65% and 85%,
and the maxillary lateral incisors
about 70%.26 Only in cases in which
the main cause is hyperactive lip is
the lip repositioning surgery as de-
scribed in this study indicated.
A second step in obtaining
success in any treatment is suitable
case selection. The technique re-
ported here was used in the treat-
ment of excessive gingival display
due to hyperfunction of the upper
lip elevator muscle. According to
Garber and Salama,2 the normal
shift of the upper lip during smiling
is 6 to 8 mm and is increased by 1.5
to 2 times in cases of hyperactiv-
ity of the upper lip. In these cases,
when a patient smiles, the upper
lip moves apically, exposing a large
amount of gingiva, which is not
considered esthetic. In patient no.
1, it was found that 7 mm of gingi-
va was displayed while smiling and
the upper lip moved 12 mm api-
cally, presenting none of the other
features to consider, leading to a
diagnosis of hyperactive upper lip.
In patient no. 2, 6 mm of gingiva
was displayed during smiling with
11 mm of apical lip movement.
However, short crowns due to al-
tered passive eruption type 1A,2,27
with a 2-mm distance between the
alveolar bone crest and CEJ, were
also diagnosed. This indicated a
need for gingivectomy, without os-
teotomy, to increase crown length
and complement the treatment of
the gummy smile.
Volume 33, Number 3, 2013
314
Several other techniques for
excessive gingival display have
been used in cases of hyperactive
upper lip, with a wide variation in
outcomes. Detachment of the lip
muscles,15 myectomy and partial
muscle removal,16 lengthening of
the lip associated with rhinoplas-
ty,14 and, recently, use of botulinum
toxin12,13 are examples of treat-
ment modalities described in the
literature. For patients and dental
professionals who desire a more
conservative technique, surgical lip
repositioning is a viable alternative.
In technique selection, the pro-
cedure shown in this case report
could be the first choice because it
is less invasive and presents good
stability during the 6-month follow-
up.
The literature shows only clini-
cal case reports for gummy smile
treatment. More studies with a
greater number of patients and with
long-term follow-up are necessary
to increase the level of scientific evi-
dence for such procedures.
Conclusion
The modified lip repositioning
technique to decrease the amount
of gingival display in patients with
hyperfunction of the upper lip el-
evator muscle was shown to be
more conservative and provid-
ed good esthetic outcomes in a
6-month follow-up. In a long-term
evaluation, other studies will be
necessary to assess the stability
and effectiveness of this technique.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Acknowledgment
The authors wish to express their gratitude
to Dr Dimitris N. Tatakis (The Ohio State
University College of Dentistry, Columbus,
OH) for his assistance with the manuscript.
The authors reported no conflicts of interest
related to this study.
References
 1. Tjan AH, Miller GD, The JG. Some es-
thetic factors in a smile. J Prosthet Dent
1984;51:24–28.
 2. Garber DA, Salama MA. The aesthetic
smile: Diagnosis and treatment. Peri-
odontol 2000 1996;11:18–28.
 3. Peck S, Peck L, Kataja M. The gingival
smile line. Angle Orthod 1992;62:91–100.
 4. Silberberg N, Goldstein M, Smidt A.
Excessive gingival display: Etiology, di-
agnosis, and treatment modalities. Quin-
tessence Int 2009;40:809–818.
  5. Evian CI, Cutler SA, Rosenberg ES, Shah
RK. Altered passive eruption: The undi-
agnosed entity. J Am Dent Assoc 1993;
124:107–110.
 6. Dolt AH III, Robbins JW. Altered pas-
sive eruption: An etiology of short clinical
crowns. Quintessence Int 1997;28:363–372.
 7. Weinberg MA, Eskow RN. An overview
of delayed passive eruption. Compend
Contin Educ Dent 2000;21:511–514.
 8. Allen EP. Use of mucogingival surgical
procedures to enhance esthetics. Dent
Clin North Am 1988;32:307–330.
  9. Allen EP. Surgical crown lengthening for
function and esthetics. Dent Clin North
Am 1993;37:163–179.
10. Kokich VG. Esthetics: The orthodontic-
periodontic restorative connection. Se-
min Orthod 1996;2:21–30.
11. Kim TW, Kim H, Lee SJ. Correction of
deep overbite and gummy smile by us-
ing a mini-implant with a segmented wire
in a growing class II division 2 patient.
Am J Orthod Dentofacial Orthop 2006;
130:676–685.
12. Polo M. Botulinum toxin type A in the
treatment of excessive gingival display.
Am J Orthod Dentofacial Orthop 2005;
127:214–218.
13. Mazzuco R, Hexsel D. Gummy smile and
botulinum toxin: A new approach based
on the gingival exposure area. J Am
Acad Dermatol 2010;63:1042–1051.
14. Ezquerra F, Berrazueta MJ, Ruiz-Ca-
pillas A, Arregui JS. New approach to
the gummy smile. Plast Reconstr Surg
1999;104:1143–1150.
15. Litton C, Fournier P. Simple surgical cor-
rection of the gummy smile. Plast Recon-
str Surg 1979;63:372–373.
16. Miskinyar SA. A new method for correct-
ing a gummy smile. Plast Reconstr Surg
1983;72:397–400.
17. Rubinstein AM, Kostianovsky AS. Cirugia
estetica de la malformacion de la sonrisa.
Pren Med Argent 1973;60:952.
18. Rosenblatt A, Simon Z. Lip repositioning
for reduction of excessive gingival dis-
play: A clinical report. Int J Periodontics
Restorative Dent 2006;26:433–437.
19. Simon Z, Rosenblatt A, Dorfmann W.
Eliminating a gummy smile with surgical
lip repositioning. J Cosmet Dent 2007;
23:100–108.
20. Humayun N, Kolhatkar S, Souiyas J,
Bhola M. Mucosal coronally positioned
flap for the management of excessive
gingival display in the presence of hy-
permobility of the upper lip and vertical
maxillary excess: A case report. J Peri-
odontol 2010;81:1858–1863.
21. De Souza Pinto EB, Da Rocha RP, Filho
WQ, et al. Anatomy of the median part
of the septum depressor muscle in aes-
thetic surgery. Aesthetic Plast Surg 1998;
22:111–115.
22. Rohrich RJ, Huynh B, Muzaffar AR, Ad-
ams WP Jr, Robinson JB Jr. Importance
of the depressor septi nasi muscle in rhi-
noplasty: Anatomic study and clinical ap-
plication. Plast Reconstr Surg 2000;105:
376–383.
23. Zahrani AA. Correction of vertical maxil-
lary excess by superior repositioning of
the maxilla. Saudi Med J 2010;31:695–702.
24. Fradeani M. Evaluation of dentolabial
parameters as part of a comprehensive
esthetic analysis. Eur J Esthet Dent 2006;
1:62–69.
25. Gargiulo A, Weinz F, Orban B. Dimen-
sions and relations at the dentogingival
juncion in humans. J Periodontol 1961;
132:261–267.
26. de Castro MV, Santos NC, Ricardo LH. As-
sessment of the “golden proportion” in
agreeable smiles. Quintessence Int 2006;
37:597–604.
27. Levine RA, McGuire M. The diagno-
sis and treatment of the gummy smile.
Compend Contin Educ Dent 1997;18:
757–762.
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