Clinical Oral Investigations

https://doi.org/10.1007/s00784-021-03896-7

ORIGINAL ARTICLE

Lip repositioning surgery for gummy smile: 6-month clinical

and radiographic lip dimensional changes
Reem I. Andijani 1,2 & Vanessa Paramitha 1 & Xiaohan Guo 3 & Toru Deguchi 4 & Dimitris N. Tatakis 1

Received: 15 February 2021 / Accepted: 16 March 2021

# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objectives The present case series aimed to examine lip repositioning surgery (LRS) outcomes related to changes in external and
internal upper lip (UL) dimensions, utilizing both conventional clinical and novel radiographic approaches.
Materials and methods Patients (n = 13) diagnosed with hypermobile UL (>8-mm mobility during smile) and excessive gingival
display (≥4-mm) were included and assessed at baseline and 6 months postoperatively. Clinical parameters at rest included total
lip and internal lip length (vestibular depth). At maximum smile included total lip, philtrum (ergotrid), and vermilion lengths.
Cephalometric parameters included anterior maxillary height; lip length; nasolabial angle; anteroposterior lip thickness; internal
lip length (vestibular depth); and vestibular fornix position (using novel approach employing radiopaque marker). Linear mixed-
effect models, Pearson’s correlation, and linear regression were used for statistical analyses.
Results LRS did not affect total UL length at rest (p = 0.418). It resulted in significant internal UL length decrease (−3.8 ± 2.1
mm, p < 0.001) and significant increases of vermilion length (1.9 ± 1.0 mm, p < 0.001) and anteroposterior lip thickness (0.7 ± 0.7
mm, p = 0.002). The clinical and radiographic measurements of total UL length at rest (r ≥ 0.734) and of internal UL length (r ≥
0.737), and the two radiographic assessments of vestibular depth (r = 0.842), were strongly correlated.
Conclusions LRS resulted in significant decrease of vestibular depth/internal UL length and in significant increases of UL vertical
vermilion length and UL anteroposterior thickness, without affecting total UL length at rest.
Clinical relevance The documented lip dimensional outcomes should help practitioners when treatment-planning LRS and
counseling patients seeking treatment for hypermobile UL.

Keywords (MESH): Esthetics . Dental . Lip . Mouth mucosa . Plastic surgery . Smiling

Introduction (VME) [1]. HUL, which can be addressed by lip repositioning

Excessive gingival display (EGD) during smiling, commonly
referred to as gummy smile (GS), can result from several
different etiologies, such as altered passive eruption (APE),
hypermobile upper lip (HUL), and vertical maxillary excess
* Dimitris N. Tatakis
tatakis.1@osu.edu
1
Division of Periodontology, College of Dentistry, The Ohio State
University, 305 West 12th Avenue, Columbus, OH 43210, USA
2
Dentistry Administration, King Fahad Medical City,
Riyadh, Kingdom of Saudi Arabia
3
Department of Statistics, College of Arts and Sciences, The Ohio
State University, Columbus, OH, USA
4
Division of Orthodontics, College of Dentistry, The Ohio State
University, Columbus, OH, USA
surgery (LRS), is highly prevalent among persons with EGD
[2]. LRS, first described in the plastic surgery literature in the
early 1970s [3, 4], consists of removal of a strip of intraoral
mucosa from the buccal vestibule, typically outlined by the
mucogingival junction (MGJ) coronally, the labial commis-
sures during smiling laterally, and a line parallel to the MGJ
apically. The margin of the apical incision is then coronally
advanced and sutured to the MGJ. This results in reduced
vestibular depth and restriction of upper lip (UL) movement,
hence decreasing the amount of gingival display (GD).
Despite the almost 50-year history of LRS, very few stud-
ies have documented quantified procedure outcomes. The
original reports provided only surgical technique descriptions
and qualitative assessments [3–5]. A few recent studies have
reported quantitative outcomes, almost exclusively focused on
EGD outcomes [6–12]. The results indicate that LRS signifi-
cantly decreases EGD [6–11, 13] and increases upper lip

length during smiling [7, 10, 13]. Although vestibular depth
(internal lip length) reduction is an inherent element of LRS,
there are no studies that have investigated either the magnitude
or the dynamics of the upper lip internal length changes fol-
lowing this surgical procedure.
Of the various upper and lower lip anatomical dimensions,
e.g., width, length, and volume, the apico-coronal length of
the upper lip vermilion (also referred to as vertical lip thick-
ness [14], upper red lip height [15], or upper lip/upper vermil-
ion fullness [16]) is an esthetically critical determinant when
judging pleasantness of a smile [14]. This lip dimension has
been examined from both frontal and lateral views [17–19].
Although changes in upper lip dimensions after LRS have
been quantified using frontal views [7, 10, 13], the possible
LRS effects on lip dimensions analyzed in lateral views have
not been quantified, either clinically or radiographically.
The aim of the present case series was to analyze LRS
effects related to changes in internal (vestibule) and external
upper lip dimensions, by investigating clinical outcomes,
using conventional approaches, and radiographic outcomes,
using a novel radiographic approach.
Materials and methods
Study design and study population
This prospective case series study was undertaken at the
Graduate Periodontics Clinic, The Ohio State University
College of Dentistry. Study recruitment occurred between
January 2017 and September 2018. Patients were recruited
using fliers distributed in the College of Dentistry and adver-
tisements sent via mail and e-mail. The study announcements/
advertisements asked whether potential patients had a GS and
whether they were interested in participating in a research
study to treat their GS. The study was approved by the
Institutional Review Board of the Ohio State University (pro-
tocol #2016H0336) and was conducted in accordance with the
Helsinki Declaration of 1975, as revised in 2013. All partici-
pants provided written informed consent after receiving de-
tailed verbal and written information regarding the study.
Interested patients were first screened by phone for the
following eligibility criteria: age >18 years old; non-smoker;
good general health; presence of upper teeth; GS they would
like to treat; be available for 1 screening and 6 additional visits
over 6 months; and being non-pregnant for females. Those
who met the above criteria were invited for clinical screening.
At the clinical screening appointment, medical history and
medications were reviewed, and a periodontal examination
was conducted to determine periodontal health status.
Physical status was classified according to the American
Society of Anesthesiologists [20]. Periodontitis was diag-
nosed according to the American Academy of
Clin Oral Invest
Periodontology update to the 1999 classification system
[21]. Final eligibility was based on the following additional
inclusion criteria: periodontally healthy; >8-mm upper lip mo-
bility during maximum smile (i.e., HUL diagnosis) [2]; and
≥4-mm GD [7]. GD and upper lip mobility from rest to max-
imum smile were measured over the maxillary right central
incisor [2, 7], using a calibrated custom-made millimeter ruler
[2] (Fig. 1a). Patients diagnosed with APE [2] or showing
increased lower facial height (VME) [22] were excluded.
The study sample size was based on prior published LRS
outcomes on lip length changes [7]. A study with 13 partici-
pants has greater than 80% power at alpha = 0.05, assuming a
0.67 effect size.
Surgical procedure and postoperative protocol
LRS was performed by an experienced periodontist (DNT), as
described by Rosenblatt and Simon [23] (Supplementary Fig.
1). The lip midline, demarcated by the maxillary labial fre-
num, and incision outlines were marked using a surgical
marker pen. Following establishment of anesthesia, a partial
thickness horizontal incision was made ~1-mm coronal to the
MGJ, extending laterally to the most distal GD extent during
maximum smile. At each distal end of this first incision, a
partial thickness vertical incision was made in an apical direc-
tion. The length of these incisions was twice the GD (in mm)
during maximum smile but did not exceed 12 mm. The two
vertical incisions were then connected with a partial thickness
horizontal incision parallel to the initial incision. The island of
mucosa thus outlined was dissected and discarded, with the
underlying connective tissue left intact (Supplementary Fig.
1a). The two horizontal wound edges were then approximated
and sutured using simple interrupted absorbable (polyglycolic
acid) sutures (Supplementary Fig. 1b). A single strip of surgi-
cal tape (Henry Schein, item #1012323) was applied horizon-
tally across the upper lip on both sides, extending out to the
base of the zygoma. Patients were instructed to leave the tape
for the first 24–48 h after the procedure, and to minimize
upper lip movement until the first postoperative visit.
Patients were prescribed ibuprofen (600 mg every 6 h for 2
days, then as needed) and 0.12% chlorhexidine rinse (0.5 oz
for 30 s twice daily for 1 week). Patients unable to take ibu-
profen were prescribed acetaminophen (500–1000 mg every
6 h for 2 days, then as needed). All patients were seen post-
operatively at 1 week, 2 weeks (suture removal for all pa-
tients), and at 1, 3, and 6 months.
Study parameters
A. Clinical parameters
All clinical parameters were recorded and analyzed by two
trained and calibrated examiners (RIA; VP). Patients held a
Clin Oral Invest
Fig. 1 Clinical external upper lip
measurements. a At rest position:
total upper lip length (white
arrow); note ruler in place. b At
maximum smile: 1, total upper lip
length; 2, philtrum length; 3,
vermilion length
customized, disposable ruler slightly distal to the maxillary right
central incisor, and frontal photographs were taken at rest and at
maximum smile positions (Fig. 1a and 1b). Photographs were
taken using a professional digital camera held parallel to the
horizontal plane, ~150 cm away from the patient’s face, and
focused on the area between the nose and chin [24].
Photographs were taken at baseline; day of LRS (for internal
lip measurement); and at 3 and 6 months postoperatively.
Photographs were analyzed using a digital image analysis soft-
ware (NIH ImageJ version v1.51j8; https://imagej.nih.gov/ij/).
Measurements at rest position
1. Total upper lip length: measured from the base of the nose
to the inferior border of the lip (mid-lip) [25] (Fig. 1a).
2. Maxillary vestibular depth/internal lip length: measured
using a commercially available (Esthetic Lip Ruler,
GDIT, Tulsa, OK, USA) modified internal lip ruler [26]
(Fig. 2a). The upper lip was slightly elevated; the ruler
was positioned at the center of the upper vestibule and
gently pushed to the bottom of the vestibule until the
patient reported contact without pressure. The lip was
then released and, if needed, gently moved to verify that
it was not folded over or under tension. Once the patient
confirmed lack of pressure, the clinical photograph was
taken and used to obtain the measurement (Fig. 2b). To
account for possible ruler positioning error, 2–4 photo-
graphs were obtained, with the ruler fully removed and
re-inserted each time. The measurement, recorded as the
internal lip length, was obtained from two photographs
whose measurements matched.
Measurements at maximum smile position
1. Total upper lip length: measured from the base of the nose
to the inferior border of the lip at the level of the gingival
zenith of the right central incisor (Fig. 1b)
2. Philtrum (ergotrid) length: measured from the base of the
nose to the superior border of the vermilion at the level of
the gingival zenith of the right central incisor (Fig. 1b)
3. Upper lip vermilion length: measured at level of the gin-
gival zenith of the right central incisor area (Fig. 1b)
To determine intra-examiner reliability, nine photo-
graphs (3 each at rest, 3-month, and 6-month maximum
smile) were randomly selected. All clinical parameters
were measured on each photograph in triplicate, each mea-
surement at least 12 h apart. The intraclass correlation co-
efficients (ICC) for the two examiners ranged between
0.92 and 0.99. For inter-examiner reliability, the two ex-
aminers independently measured all parameters on 4 addi-
tional photographs (2 each at rest and at maximum smile)
and the resulting ICC was 0.97.
B. Radiographic parameters
Digital cephalometric radiographs were taken at rest posi-
tion at baseline and at 6 months postoperatively. Radiographs
were taken after radiopaque slurry [27] was applied at the
depth of the vestibule (Fig. 2c), on the right side of the max-
illary labial frenum. The radiopaque slurry composed of a
mixture (1:1 by volume) of root canal sealer (Tubli-Seal,
Kerr Corporation, Romulus, MI, USA) and barium sulfate
(E-Z-HD, Barium Sulfate for Suspension, EZEM Canada
Inc., Anjou, QC, Canada). The radiopaque marker allowed
for radiographic measurement of the internal lip length (Fig.
2d), which aimed to confirm the clinical measurement obtain-
ed with the specialized ruler detailed above. Cephalometric
radiographs were traced using a commercial software
(Dolphin Imaging Premium version 11.9; https://www.
dolphinimaging.com). The following points were used for
cephalometric analysis (Figs. 2d and 3):
1. Anterior nasal spine (ANS): the tip of the anterior nasal
spine
2. Columella point (Cm): the most anterior point of the col-
umella of the nose
3. Incisal edge (IE) of the central incisor

Fig. 2 Internal lip length/vestibular length measurements. a Modified
internal lip ruler. b Clinical measurement (line denotes 20 mm). c
Radiographic marker (radiopaque slurry) application. d Radiographic
4. Labrale superius (Ls): the most prominent border of the
upper lip vermilion
5. Posterior nasal spine (PNS): the tip of the posterior nasal
spine
6. Radiopaque marker (RM): the most coronal and anterior
point of the radiopaque slurry
7. Stomion superius (Stms): the lowest point of the upper lip
8. Subnasale (Sn)
9. T point (T): represents a point on the vestibular aspect of
the lip at the level of the central incisor cementoenamel
junction
The following cephalometric parameters were recorded
(Figs. 2d and 3):
Fig. 3 Radiographic landmarks and measurements (see text for details).
Landmarks: ANS, anterior nasal spine; Cm, columella point; IE, incisal
edge; Ls, labrale superius; PNS, posterior nasal spine; PP, palatal plane;
RM, radiopaque marker; Stms, stomion superius; Sn, subnasale; T, point
on vestibular aspect of upper lip at the level of the central incisor
cementoenamel junction. Measurements: 1, upper lip length (Sn-Stms);
2, upper lip thickness (Ls-T); AMH, anterior maxillary height; NLA,
nasolabial angle
Clin Oral Invest
measurements: 1, RM-Stms (internal lip length); 2, RM-IE (vestibular
fornix position). Radiographic landmarks: IE, incisal edge; RM, radi-
opaque marker; Stms, stomion
1. Anterior maxillary height (AMH): vertical distance from
IE to palatal plane (PP) [28, 29]
2. Upper lip length (LL): distance from Sn to Stms [29]
3. Ratio of upper lip length to anterior maxillary height (LL/
AMH) [29]
4. Nasolabial angle (NLA = Cm-Sn-Ls) [29]
5. Upper lip thickness (LT = Stms-T): from the facial to the
vestibular aspect of the lip [30, 31]
6. Internal lip length (RM-Stms)
7. Vestibular fornix position (RM to IE)
Cephalometric tracing and manual measurements of RM-
Stms, and RM-IE were performed by one blinded, experienced,
and calibrated orthodontist (TD). To determine examiner reli-
ability, measurements were repeated after 4 weeks, and the
calculated measurement error [32] was 0.18 mm. AMH, LL,
and LT were measured manually by one trained examiner
(RIA). To determine intra-examiner reliability, 9 randomly se-
lected radiographs (baseline and 6 months) were used to per-
form measurements in triplicate; the resulting ICC was 0.97.
Data analysis
Collected data was organized onto a spreadsheet format.
Descriptive statistics, e.g., measures of central tendency and dis-
persion, were calculated. The association between clinical mea-
sures and time was analyzed using linear mixed-effect model
(LMM). Tukey’s adjustment was used in the pairwise compari-
sons among clinical parameters at three time points. Pearson’s
correlations were calculated to measure the agreement between
clinical and radiographic parameters at each time point separately.
Significance level was set at a = 0.05. Analyses were performed
using the R Software, version 3.6.0 (https://www.R-project.org/).
Results
Thirteen patients (age: 24.7 ± 3.5 years; range: 19–29 years;
all ASA I; 12 females) were recruited and completed the
Clin Oral Invest

study. Healing of all patients was within normal limits. During
the first postoperative week, one patient developed an
aphthous ulcer in the left maxillary vestibule, apparently un-
related to any incision or suture; the ulcer self-resolved by the
2-week postoperative visit.
Clinical parameters Clinical measurements of upper lip out-
comes are shown in Table 1. Figure 4 illustrates a representa-
tive case before and after LRS. Total lip length at rest was 21.9
± 2.1 mm at baseline and did not change significantly either at
3 or 6 months postoperatively (p = 0.418). Total lip length at
maximum smile was 13.7 ± 2.0 mm at baseline and was sig-
nificantly increased at both the 3-month (16 ± 1.9 mm) and the
6-month postoperative visits (15.5 ± 2.1 mm) (p < 0.001),
without significant differences between 3 and 6 months (p =
0.455). Vermilion length changed significantly (p < 0.001)
from baseline (4.8 ± 1.3 mm) to 3 (6.8 ± 11 mm) or 6 months
postoperatively (6.6 ± 1.3 mm), with no significant change
between the two postoperative visits (p = 0.835). Philtrum
length was 8.9 ± 2.2 mm at baseline and remained unchanged
at either the 3-month or the 6-month visits (p = 0.445).
There was significant change in the internal lip length with
time (p < 0.001); immediately after LRS, it decreased from
18.0 ± 3.0 to 11.3 ± 2.1 mm. At 3 and 6 months postopera-
tively, internal lip length increased to 14.4 ± 2.4 mm and 14.3
± 2.0 mm, respectively, with no significant difference between
the two postoperative visits (p = 0.999). However, the differ-
ence between baseline and 6-month measurements was sig-
nificant (p < 0.001).
Radiographic parameters The radiographic lip outcomes are
presented in Table 2. Figure 4 illustrates a representative case
before and after LRS. The AMH was 31.4 ± 2.1 mm at base-
line and remained unchanged postoperatively (p = 0.514).
Baseline LL, which corresponds to the clinical measurement
of total lip length at rest, was 22.0 ± 1.6 mm and also remained
unchanged postoperatively (p = 0.663). Consequently, the LL/
AMH ratio (~0.7%) also remained unchanged (p = 0.559).
NLA was 114.1 ± 5.9 degrees at baseline and did not change
significantly postoperatively (p = 0.111). LT changed signif-
icantly from 12.3 ± 1.3 mm at baseline to 13.0±1.1 mm post-
operatively (p = 0.002). The RM-Stms length, which corre-
sponds to the clinically determined internal lip length, de-
creased significantly from 17.8 ± 2.2 mm at baseline to 14.1
± 2.2 mm at 6 months (p < 0.001). Similarly, the RM-IE
length decreased significantly from 21.2 ± 2.4 mm at baseline
to 17.9 ± 2.4 mm at six months (p < 0.001).
Correlations between parameters There was a strong correla-
tion between the clinical and radiographic measurements of
total upper lip length at rest, both at baseline (r = 0.734) and at
6 months postoperatively (r = 0.869). Similarly, there was a
strong correlation between the clinical and radiographic mea-
surements of internal lip length at rest, both at baseline (r =
0.812) and at 6 months (r = 0.737). Furthermore, there was a
strong correlation between the two radiographic measure-
ments of vestibular depth: RM-Stms and RM-IE (r = 0.842).
Discussion
The present study sought to investigate, using both clinical
and radiographic quantitative assessments, the upper lip di-
mensional changes following lip repositioning surgery

Table 1 Clinical parameters over time

Baseline 3 months 6 months Change (baseline to 6 months) p-value

At rest position
Total lip length 21.9 ± 2.1 22.2 ± 2.0 22.1 ± 1.9 0.2 ± 1.0 0.418
(22.2; 18.2–24.1) (22.6; 19.0–26.3) (22.1; 19.1–24.9) (0.1; −1.8–1.5)
Internal lip length (vestibule depth) Pre-surgery 14.4 ± 2.4 14.3 ± 2.0 −3.8 ± 2.1 <0.001
18.0 ± 3.0 (14.5; 10.0–18.0) (14.5; 10.0–18.0) (−3.5; −8.5–(−0.5))
(18.5; 13.0–23.0)
End of surgery
11.3 ± 2.1
(11.5; 8.0–15.0)
At maximum smile
Total lip length 13.7 ± 2.0 16.0 ± 1.9 15.5 ± 2.1 1.8 ± 1.6 <0.001
(14.0; 9.7–16.0) (15.8; 13.5–20.2) (14.9; 12.7–19.0) (1.6; −1.9–4.0)
Philtrum length 8.9 ± 2.2 9.2 ± 2.0 8.9 ± 1.8 0.0 ± 1.3 0.445
(9.0; 4.0–12.3) (9.5; 5.9–13.6) (8.6; 6.1–12.2) (−0.2; −2.5–2.2)
Vermilion length 4.8 ± 1.3 6.8 ± 1.1 6.6 ± 1.3 1.9 ± 1.0 <0.001
(4.9; 2.9–7.3) (7.1; 4.4–8.1) (6.4; 4.4–8.6) (2.0; −0.4–3.1)

Values (in mm) are mean ± SD (median; range). All values based on n = 13. p-values are for the tests of difference in parameters among the three time
points; bold values indicate statistical significance
 Clin Oral Invest

Fig. 4 Representative clinical (a, b) and radiographic (c, d) outcomes. Stms, stomion superius. Radiographic measurements: 1, RM-Stms (inter-
Compare baseline (a, c) with 6-month postoperative (b, d) images. nal lip length); 2, RM-IE (vestibular fornix position)
Radiographic landmarks: IE, incisal edge; RM, radiopaque marker;

(LRS) applied to the treatment of excessive gingival display
(EGD) due to hypermobile upper lip (HUL). The results indi-
cate that, at maximum smile, LRS outcomes include signifi-
cant increases in vertical vermilion length and total lip length.
At rest, LRS resulted in a significant decrease of internal lip
length (vestibular depth) and a significant increase in
anteroposterior lip thickness at the vermilion level, in the ab-
sence of any changes in external lip dimensions. This is the
first LRS study to examine at rest total lip length and internal
lip length outcomes and to provide radiographic assessment of
soft tissue changes following LRS, including anteroposterior
lip thickness. The novel findings provide new insights into the
lip-specific outcomes of this surgical procedure and should
help practitioners when recommending or treatment-
planning LRS. Several of the data reported for the first time
in the present study provide the foundation for future research
on parameters that could contribute to HUL development.
LRS is one of several procedures available to treat HUL,
which was recently reported to be the most prevalent EGD
etiology [2]. EGD being the main indication for LRS [3–5, 7],
most studies reporting quantitative LRS outcomes focus on
GD changes [6–11, 13]. Similar to most reported LRS studies
[6–11, 13], GD was significantly decreased at both 3-month
and 6-month postoperative assessments in the present study,
and the magnitude of GD reduction paralleled the reported
total lip length increase (data not shown), in agreement with
previously detailed findings [7]. However, LRS is a procedure
that directly affects the upper lip by reducing the available
mobile vestibular mucosa [3–5, 7, 23]. Hence, the present
study focused on lip-specific outcomes. The findings indicate
that, when assessed during maximum smile, LRS results in
significant increases in upper vermilion vertical length, a di-
mension also referred to as vertical lip thickness [14], upper
red lip height [15], upper lip/upper vermilion fullness [16], or
visible lip body [13]. This is consistent with the findings of
previous LRS studies when analyzed under similar conditions
(maximum or active smile) [7, 13]. Quantitatively, the vermil-
ion changes reported here (~40% increase over baseline) ap-
pear greater than in previous reports (20–23% increase) [7,
13]. These differences may be due to differences in surgical

Table 2 Radiographic parameters

over time Baseline 6 months Change (baseline to 6 months) p-value

AMH (mm) 31.4 ± 2.1 31.3 ± 2.4 −0.1 ± 0.7 0.514

(31.3; 28.5–34.8) (31.5; 27.7–35.1) (0.0; −2.5–0.5)
LL (mm) 22.0 ± 1.6 22.0 ± 1.7 0.0 ± 0.2 0.663
(22.6; 19.1–24.7) (22.5; 19.2–25.1) (0.0; −0.3–0.4)
LL/AMH (%) 0.7 ± 0.0 0.7 ± 0.1 0.0 ± 0.0 0.559
(0.7; 0.6–0.8) (0.7; 0.6–0.8) (0.0; 0.0–0.1)
NLA (degrees) 114.1 ± 5.9 116.3 ± 6.1 2.2 ± 4.7 0.111
(115.3; 101.7–122.2) (117.0; 106.5–125.8) (3.1; −7.8–9.5)
LT (mm) 12.3 ± 1.3 13.0 ± 1.1 0.7 ± 0.7 0.002
(12.2; 10.2–14.5) (12.7; 11.4–14.7) (0.7; −0.2–2.3)
RM-Stms (mm) 17.8 ± 2.2 14.1 ± 2.2 −3.7 ± 1.5 <0.001
(18.3; 13.9–22.0) (13.9; 10.5–17.6) (−4.4; −5.7–(−1.1))
RM-IE (mm) 21.2 ± 2.4 17.9 ± 2.4 −3.3 ± 1.3 <0.001
(21.5; 17.5–26.1) (18.1; 14.1–22.8) (−3.4; −4.9–(−1.1))

Values are mean ± SD (median; range). All values based on n = 13. p-values are for the tests of difference in
parameters between time points; bold values indicate statistical significance
AMH, anterior maxillary height; IE, incisal edge; LL, upper lip length; LT, lip thickness; NLA, nasolabial angle;
RM, radiopaque marker; Stms, stomion superius
Clin Oral Invest
and assessment methods and in baseline values. The vertical
length of the upper vermilion is an esthetically critical deter-
minant, for both professionals and laypeople, when judging
pleasantness of a smile [14], which suggests that the LRS-
resulting increase in vertical vermilion dimension contributes
to the improved patient satisfaction with their postoperative
smile [7, 13]. This hypothesis can be tested and merits further
investigation.
In the present study, total lip length at maximum smile was
also significantly increased after LRS. This change is attribut-
able to the vermilion dimensional change; the philtrum
(ergotrid) length remained unchanged, while the total lip
length increase quantitatively matched the vermilion dimen-
sional change. The discrepancy between the results of Silva
et al. [7], who reported that philtrum length at smile increased
postoperatively, and the present study may be due to the dif-
ferent surgical technique and assessment methods.
LRS did not affect total lip length at rest. The consistency
between clinical and radiographic assessments of this param-
eter lends further strength to this novel finding. Previous LRS
studies have not reported direct total lip length measurements
at rest. This finding should be an important consideration for
patients, because it means that this surgical procedure, while it
helps improve their smile, does not alter their normal appear-
ance at rest.
As originally described and as performed in the present
study, LRS consists of the removal of a mucosal strip and
the approximation of the resulting wound edges, resulting in
shortening of the vestibule. Even though vestibular shortening
constitutes the essence of this surgical procedure, no studies
until now addressed LRS outcomes in terms of vestibular
depth/internal lip length. The results reported here indicate
that LRS significantly decreased internal lip length (vestibular
depth), as determined clinically. The baseline internal lip
length recorded in the present population of HUL patients
was significantly longer compared to the corresponding mea-
surement (14.8 ± 0.23 mm) in female volunteers (of similar
age) with presumed normal lip mobility (44% of them had low
or average smile line) [26]. In contrast, comparison of external
total lip length between these two groups reveals much small-
er differences (< 1 mm on average). Collectively, these find-
ings suggest a conceivable association between vestibular
depth/internal lip length and HUL; the potential contribution
of a deeper vestibule/greater internal lip length to HUL could
be explored further.
Although the use of a modified internal lip ruler to measure
vestibular length during smile has been previously reported in
randomly selected volunteers [26], such measurements have
not been corroborated by other means. Therefore, the present
study introduced a novel radiographic approach to measure
the internal lip length, by applying a radiopaque marker
(RM) at the depth of the vestibule. The consistency and strong
correlation between clinical and radiographic assessments of
this parameter validate the study outcomes. Nonetheless, doc-
umentation of LRS-induced internal lip length changes,
whether clinically or radiographically, based on a soft tissue
landmark (Stms: Stomion superius; the lowermost point on
the vermilion of the upper lip) represented a concern because
of the possibility that the Stms position itself could be affected
by the surgical procedure. To mitigate this potential limitation,
a fixed, hard tissue landmark (IE: incisal edge of maxillary
central) was also used to record vestibular depth changes. The
strong correlation between the two radiographic measure-
ments (RM-Stms and RM-IE) and the negligible quantitative
difference in the vestibular depth changes recorded by these
two measurements (0.4 mm on average) corroborates the clin-
ically recorded vestibular changes and suggests that Stms re-
mains fairly stable after LRS. Stms positional stability is con-
sistent with the finding that total lip length at rest remained
unchanged following this procedure.
LRS-related upper lip changes from a lateral view have not
been previously investigated. The use of cephalometric radio-
graphs allowed quantification of anteroposterior lip dimension
changes following this procedure. The results indicate that, at
rest, anteroposterior lip thickness at the level of the vermilion
increases significantly after LRS. Whether this change con-
tributes to improved esthetics from a profile perspective re-
mains to be determined.
As anticipated, LRS did not result in any changes for the
parameters (AMH) associated with hard tissue cephalometric
landmarks. The mean AMH of the present study population
matches the reported AMH of females with ≥2 mm GD (31.7
± 3.1 mm) [28] and is greater than the AMH (28.7 ± 2.6 mm)
of a control female group with 0.7-mm average GD [28].
Although several studies have reported significantly greater
AMH in patients with GS than those without [28, 29, 33],
no studies have analyzed AMH based on GS etiology. These
findings collectively suggest the possibility that HUL may be
associated with increased AMH. The mean ratio of total lip
length/AMH in the present study was 70%. Wu et al. (2010)
reported a mean ratio of 74% in females with GS that was
significantly smaller than in females without GS (77%) [29].
The available evidence indicates that there is no difference in
at rest total lip length between those with and without GD
[28]. Future research on the potential association of HUL with
AMH, or with the uninvestigated possible interaction between
AMH and internal lip length/vestibular depth, could shed fur-
ther light on HUL development.
The present study is not without limitations. The study
population was almost entirely female (92%). However, the
female-dominated demographics are strongly consistent with
the demographics of previous LRS studies [6–10, 13], the
gender distribution (86% female) of patients requesting to
treat their EGD [2], and the fact that females tend to be more
critical regarding their smiles/esthetics than males [34, 35].
The follow-up time of 6 months is relatively short, but within

the reported range of most LRS studies [12]. The possibility of
at least partial relapse after a 6-month follow-up, attributed
possibly to muscle memory [36], suggests that longer
follow-up periods are needed to establish the long-term stabil-
ity of the reported LRS lip outcomes.
Conclusions
LRS, performed to treat HUL-associated EGD, resulted in
significant decrease of vestibular depth/internal UL length
and in significant increases of UL vertical vermilion length
and UL anteroposterior thickness, without affecting total UL
length at rest, as determined at 6 months postoperatively. The
documented short-term lip dimensional outcomes should help
practitioners when treatment-planning LRS and counseling
patients seeking treatment for HUL. The introduced novel
radiographic approach to document upper lip dimensional
changes could help future research on various lip-modifying
interventions.
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s00784-021-03896-7.
Acknowledgements The authors thank Ms. Laura McCallister, from the
Division of Periodontology, The Ohio State University, for her expert
assistance with logistics and editorial support.
Funding This study was supported by the authors’ institution (Division
of Periodontology, College of Dentistry, The Ohio State University, in
Columbus, Ohio, USA).
Data availability Supporting data of this study are available from the
corresponding author upon request.
Declarations
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Conflict of interest The authors declare no competing interests.
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