Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-167

CASE REPORT Treatment of Gummy Smile of Multifactorial Etiology: A Case Report Monica P. Gibson* and Dimitris N. Tatakis † Introduction: This case report describes the management of a patient diagnosed with excessive gingival display caused by altered passive eruption and hyperactive lip. Treatment for this patient was staged and included esthetic crown lengthening and a subsequent lip repositioning procedure. Case Presentation: A 17-year-old female was referred for assessment of a “ gummy smile. ” The patient reported a history of mouth breathing and a sports injury causing a non-vital tooth #9, which had been temporarily restored. After peri-odontal evaluation, the patient was diagnosed with plaque-induced gingivitis and excessive gingival display due to hyper-active lip and altered passive eruption. After initial therapy, an esthetic crown lengthening procedure was performed on the maxillary anterior sextant, resulting in ideal maxillary anterior crown contours. Six weeks after esthetic crown lengthening, the patient was treated for hyperactive lip by a modified lip repositioning surgery. Subsequently, the patient received a per-manent restoration on tooth #9. During the 1.5-year follow-up time the patient repeatedly expressed her satisfaction with the improvement of her smile. Persistent mouth breathing and associated recurrent gingival inflammation remained a challenge. Conclusions: The presented case illustrates results of sequentially applied techniques for management of a gummy smile of multifactorial etiology and limitations imposed by unresolved factors. Excessive gingival display can be a significant esthetic concern for patients. Understanding the etiology can be challenging due to multiple factors that may be concom-itantly involved. Accurate diagnosis and treatment planning are critical for proper management. When multifactorial etiology is present, multiple treatment modalities, including various surgical approaches, are necessary to obtain positive outcomes in such patients. Clin Adv Periodontics 2017;7:167-173. Key Words : Alveolar bone and bones; esthetics, dental; gingiva; lip; mouth breathing; general surgery. Background Excessive gingival display (EGD), whether developmental or acquired in origin, can represent a strong esthetic concern for patients. EGD etiology varies, including gingival enlarge-ment, altered or delayed passive eruption, vertical maxillary excess, anterior dentoalveolar extrusion, short upper lip, hyperactive upper lip, and combinations thereof. 1,2 EGD resulting from skeletal deformities, such as in-creased maxillary arch vertical height, typically requires orthognathic surgery. 2-4 Altered passive eruption, often * Currently, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta School of Dentistry, Edmonton, AB; previously, Division of Periodontology, College of Dentistry, The Ohio State University, Columbus, OH. † Division of Periodontology, College of Dentistry, The Ohio State University. Submitted October 24, 2016; accepted for publication February 20, 2017 doi: 10.1902/cap.2017.160074 a cause of EGD, can be corrected by crown lengthening sur-gery (CLS), achieved through gingivectomy or an apically positioned flap with or without ostectomy depending on gingival width and alveolar bone crest location relative to the cemento-enamel junction (CEJ). 2,5 When hyperactive upper lip is the underlying EGD etiology, 2 either non-surgical (botulinum toxin injections) 6 or surgical approaches can be used for treatment. Among surgical approaches, lip repo-sitioning surgery (LRS) can reduce lip mobility during smil-ing and minimize gingival exposure. 7 Although LRS was first described in 1973, 7 a limited number of cases have been documented in the literature. 8 Silva et al. 8 recently reported the clinical and patient-centered outcomes for hyperactive lip-associated EGD treated by a modified LRS. Because of multiple possible etiologies, patients presenting with EGD should be carefully diagnosed and treatment planned accord-ingly. Clinicians must evaluate the relationships between dentition, alveolar bone, gingiva, facial skeleton, and lip to determine the underlying EGD etiology. Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017 167

Treatment Of Gummy Smile Of Multifactorial Etiology: A Case Report

Monica P. Gibson, and Dimitris N. Tatakis

Introduction: This case report describes the management of a patient diagnosed with excessive gingival display caused by altered passive eruption and hyperactive lip. Treatment for this patient was staged and included esthetic crown lengthening and a subsequent lip repositioning procedure.

Case Presentation: A 17-year-old female was referred for assessment of a “gummy smile.” The patient reported a history of mouth breathing and a sports injury causing a non-vital tooth #9, which had been temporarily restored. After periodontal evaluation, the patient was diagnosed with plaque-induced gingivitis and excessive gingival display due to hyperactive lip and altered passive eruption. After initial therapy, an esthetic crown lengthening procedure was performed on the maxillary anterior sextant, resulting in ideal maxillary anterior crown contours. Six weeks after esthetic crown lengthening, the patient was treated for hyperactive lip by a modified lip repositioning surgery. Subsequently, the patient received a permanent restoration on tooth #9. During the 1.5-year follow-up time the patient repeatedly expressed her satisfaction with the improvement of her smile. Persistent mouth breathing and associated recurrent gingival inflammation remained a challenge.

Conclusions: The presented case illustrates results of sequentially applied techniques for management of a gummy smile of multifactorial etiology and limitations imposed by unresolved factors. Excessive gingival display can be a significant esthetic concern for patients. Understanding the etiology can be challenging due to multiple factors that may be concomitantly involved. Accurate diagnosis and treatment planning are critical for proper management. When multifactorial etiology is present, multiple treatment modalities, including various surgical approaches, are necessary to obtain positive outcomes in such patients. Clin Adv Periodontics 2017;7:167-173.

Key Words: Alveolar bone and bones; esthetics, dental; gingiva; lip; mouth breathing; general surgery.

Background

Excessive gingival display (EGD),whether developmental or acquired in origin, can represent a strong esthetic concern for patients. EGD etiology varies, including gingival enlargement, altered or delayed passive eruption, vertical maxillary excess, anterior dentoalveolar extrusion, short upper lip, hyperactive upper lip, and combinations thereof.1,2

EGD resulting from skeletal deformities, such as increased maxillary arch vertical height, typically requires orthognathic surgery.2-4 Altered passive eruption, often a cause of EGD, can be corrected by crown lengthening surgery (CLS), achieved through gingivectomy or an apically positioned flap with or without ostectomy depending on gingival width and alveolar bone crest location relative to the cemento-enamel junction (CEJ).2,5 When hyperactive upper lip is the underlyingEGDetiology,2 either non-surgical (botulinum toxin injections)6 or surgical approaches can be used for treatment. Among surgical approaches, lip repositioning surgery (LRS) can reduce lip mobility during smiling and minimize gingival exposure.7 Although LRSwas first described in 1973,7 a limited number of cases have been documented in the literature.8 Silva et al.8 recently reported the clinical and patient-centered outcomes for hyperactive lip-associated EGD treated by a modified LRS. Because of multiple possible etiologies, patients presenting with EGD should be carefully diagnosed and treatment planned accordingly. Clinicians must evaluate the relationships between dentition, alveolar bone, gingiva, facial skeleton, and lip to determine the underlying EGD etiology.

This case report describes treatment of a patient diagnosed with EGD caused by altered passive eruption and hyperactive upper lip. Patient treatment was staged and included esthetic CLS and LRS.

Clinical Presentation

A 17-year-old white female was referred (May 2014) to the Graduate Periodontics Clinic of The Ohio State University College of Dentistry, Columbus, Ohio, for assessment of a “gummy smile” (Fig. 1). Her chief request was “make my smile better formy senior year pictures.” She was systemically healthy and reportedmouth breathing. She had a recent sports injury with an endodontically treated and temporarily restored tooth #9. Injury-related localized swelling of the lower lip, corresponding to the tooth #9 area,was noted. Tooth #10 was supra-erupted, unrelated to the injury. Clinical periodontal examination revealed gingival inflammation and pseudopockets (probing depth range: 3 to 6 mm). Radiographs revealed interdental bone present at, or coronal to, the maxillary anterior teeth CEJ (Fig. 2). Smile assessment revealed EGD, attributed to altered passive eruption (Coslet classification 1A)2 and hyperactive upper lip. Gingival margin position and sulcus depth relative to the CEJ informed the eruption anomaly diagnosis.9 Excess translation of the patient’s lip from repose to high smile led to a hyperactive lip diagnosis. The patient was diagnosed with plaque-induced gingivitis, gingival enlargement, and EGD.

Case Management

The treatment plan included prophylaxis, oral hygiene instruction, CLS, and LRS. The patient declined orthodontic treatment.The patient and her mother provided written informed consent for periodontal treatment. Oral prophylaxis was performed, and customized oral hygiene instructions were provided to control gingival inflammation. Moisturizing oral mouthwash‡ was recommended at bedtime to counter mouth breathing sequelae. The patient presented 5 weeks later with markedly reduced inflammation (Fig. 3). Esthetic CLS was performed on teeth #6 to #11 (Fig. 4). After local anesthesia, bone sounding was performed to confirm osseous crest position. CLS included scalloping incisions on the buccal gingiva and osseous resection to bring the bony crest 2 to 3 mm apical to the CEJ (Figs. 4a through 4c), resulting in exposure of ideal maxillary anterior crown contours (Figs. 4e and 4f). Six weeks after CLS, EGD was still present, and the patient was treated for hyperactive lip (Fig. 5). LRS, performed as previously detailed,7 entailed a partial-thickness horizontal incision, 1 mm coronal to the mucogingival junction on either side of themidline frenum until the firstmolar, a parallel incision positioned 8mm(based on amount of gingival display) apical to the first incision, and connecting incisions to allow removal of bilateral mucosal islands. The new mucosal margin was sutured (interrupted absorbable sutures) to the gingiva (Fig. 6). Patient was prescribed analgesics (ibuprofen 600 mg three times daily) for 4 days and 0.12% chlorhexidine rinse twice daily for 2 weeks. Postoperative instructions included ice pack application, soft food consumption, avoidance of mechanical trauma to treated area, and minimal possible lip movement. Sutures were removed at 2 weeks (Fig. 7). The patient was kept on strict oral hygiene follow-up postoperatively.

Clinical Outcomes

Postoperative healing was uneventful. Three months after LRS (4.5 months after CLS),10 the patient received a permanent crown on tooth #9, which further reduced inflammation between teeth #9 and #10. She reported having her senior year photo taken. During subsequent follow-up, a revision soft tissue procedure was performed between teeth #9 and #10, to reduce the enlarged papilla. This was accomplished by reflecting, thinning, and replacing the papilla (Fig. 8). The patient showed marked improvement in maxillary anterior tooth contours and reduction in gingival display for the duration of the periodic follow-up (Fig. 9), which lasted 18 months. At 18 months, recurrence of slight gingival enlargement was noted (Fig. 9). The patient repeatedly expressed her satisfaction with her smile improvement and her maxillary anterior tooth shape.

Discussion

This case report illustrates how EGD of multifactorial etiology can be successfully managed by application of indicated surgical techniques. The outcomes of these procedures appear stable 1.5 years postoperatively. The mouth breathing of the patient presented a limitation in this case because it contributed to recurrent gingival inflammation on themaxillary anterior teeth, despite her oral hygiene efforts. Furthermore, the patient’s refusal of orthodontic treatment compromised the final esthetic outcome.

There are several options to treat EGD.1,2 Choices depend upon etiology and should be decided on a case-by-case basis, taking into consideration patient preferences. This case report highlights two significant EGD etiologies: altered passive eruption and hyperactive upper lip. Esthetic CLS, to correct dentogingival discrepancies arising from altered passive eruption, and LRS, to address upper lip hyperactivity, were performed sequentially. Sequencing of these procedures is important, because it is possible to reduce or completely resolve EGD by CLS alone;5 therefore, in cases of altered passive eruption, the potentially remaining need forLRSshould be reassessed after CLS. Although possible in select cases, performing both procedures simultaneously could result in technical difficulties (lack of fixed gingival tissue for anchorage of LRS flap). Other options to treat the hyperactive lip would include treatments with botulinum toxin and myotomy.6,11-13

Overall, the presented case highlights the possibility to successfully treat a gummy smile with multiple etiologies.

Summary

Why is this case new information?

■ Treatment of EGD of multifactorial etiology accomplished by sequential performance of CLS and LRS

What are the keys to successful management of this case?

■ Case selection

■ Proper identification of etiologic factors

■ Appropriate application of indicated surgical techniques

What are the primary limitations to success in this case?

■ Unresolved factors (persistent mouth breathing) contributing to recurrent gingival inflammation

■ Refusal of orthodontic treatment leading to less than ideal final esthetic outcomes

Acknowledgment

The authors report no conflicts of interest related to this case report.

CORRESPONDENCE:

Dr. Dimitris N. Tatakis, Division of Periodontology, College of Dentistry, The Ohio State University, 4121 Postle Hall, 305 W. 12th Ave., Columbus, OH 43210. E-mail: Tatakis.1@osu.edu.

References

1.Garber DA, Salama MA. The aesthetic smile: Diagnosis and treatment. Periodontol 2000 1996;11:18-28.

2.Silberberg N, Goldstein M, Smidt A. Excessive gingival display – Etiology, diagnosis, and treatment modalities. Quintessence Int 2009;40:809-818.

3.Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg 1999;104:1143-1150.

4.Zahrani AA. Correction of vertical maxillary excess by superior repositioning of the maxilla. Saudi Med J 2010;31:695-702.

5.Silva CO, Soumaille JM, Marson FC, Progiante PS, Tatakis DN. Aesthetic crown lengthening: Periodontal and patient-centred outcomes. J Clin Periodontol 2015;42:1126-1134.

6.Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop 2008;133:195-203.

7.Rubinstein AM, Kostianovsky AS. Aesthetic surgery of the malformation of the smile (in Spanish). Prensa Med Argent 1973;60:952.

8.Silva CO, Ribeiro-Ju´ nior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: Treatment by a modified lip repositioning technique. J Clin Periodontol 2013;40:260-265.

9.Alpiste-Illueca F. Morphology and dimensions of the dentogingival unit in the altered passive eruption. Med Oral Patol Oral Cir Bucal 2012; 17:e814-e820.

10.Pilalas I, Tsalikis L, Tatakis DN. Pre-restorative crown lengthening surgery outcomes: A systematic review. J Clin Periodontol 2016;43: 1094-1108.

11.Sucupira E, Abramovitz A. A simplified method for smile enhancement: Botulinum toxin injection for gummy smile. Plast Reconstr Surg 2012; 130:726-728.

12.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.

13.Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. Myotomy of the levator labii superioris muscle and lip repositioning: A combined approach for the correction of gummy smile. Plast Reconstr Surg 2010;126:1014-1019.

indicates key references.


Currently, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta School of Dentistry, Edmonton, AB; previously, Division of Periodontology, College of Dentistry, The Ohio State University, Columbus, OH.

† Division of Periodontology, College of Dentistry, The Ohio State University.

Submitted October 24, 2016; accepted for publication February 20, 2017

doi: 10.1902/cap.2017.160074

Read the full article at http://onlinedigeditions.com/article/Treatment+Of+Gummy+Smile+Of+Multifactorial+Etiology%3A+A+Case+Report/2908804/445120/article.html.

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