the harmony of the smile is determined not only by the shape , the position , and the colour of teeth but also by the gingival tissues
it is one of the several developmental or acquired deformities and conditions that manifest in the periodontium .
it is an aesthetic concern that can affect a large portion of the population , with a reported prevalence between 10.5% and 29% . in the recent years
, egd has received an increased emphasis in dental literature and various treatment options are now available for correction of gummy smile .
the various causes of gummy smile include vertical maxillary excess , anterior dentoalveolar extrusion , altered passive eruption , short or hyperactive upper lip , or combinations thereof .
treatment of egd by esthetic crown lengthening with or without osseous resection is well documented .
egd , due to vertical maxillary excess , can be successfully treated by orthognathic surgery . however , this surgery is associated with significant morbidity and requires hospitalization .
lip repositioning results in shallow vestibule restricting the muscle pull thereby limiting the gingival display during smiling .
a 22-year - old female patient undergoing orthodontic treatment , presented with the complaint of gummy smile following retraction of maxillary anterior teeth [ figure 1 ] .
patient 's teeth were visible from maxillary right first molar to maxillary left first molar with 5 - 6 mm of gingival display .
orthognathic surgery as a treatment option was discussed with the patient . however , patient preferred less invasive lip repositioning procedure over orthognathic surgery .
adequate local anesthetic ( lignocaine 2% with epinephrine 1:100,000 ) was administered in vestibular mucosa and lip from maxillary right first molar to maxillary left first molar .
a partial thickness flap was raised from mesial line angle of left maxillary first molar to the mesial line angle of right maxillary first molar at the mucogingival junction [ figure 2 ] . a second incision 1012 mm above the first incision was made in the labial mucosa .
the two incisions were joined on either side and a strip of partial thickness flap was removed , exposing the underlying connective tissue [ figure 3 ] .
removal of split thickness flap exposed underlying connective tissue margins approximated by sutures patient was prescribed nonsteroidal anti - inflammatory drugs ( diclofenac sodium 50 mg three times daily for 3 days ) and oral antibiotics ( amoxicillin 500 mg three times daily for 5 days ) . patient was instructed to apply ice pack post operatively and minimize lip movement for 1 week .
suture line healed in the form of a scar which was covered by labial mucosa and therefore not visible on smiling [ figure 5 ] .
adequate local anesthetic ( lignocaine 2% with epinephrine 1:100,000 ) was administered in vestibular mucosa and lip from maxillary right first molar to maxillary left first molar .
a partial thickness flap was raised from mesial line angle of left maxillary first molar to the mesial line angle of right maxillary first molar at the mucogingival junction [ figure 2 ] . a second incision 1012 mm above the first incision was made in the labial mucosa .
the two incisions were joined on either side and a strip of partial thickness flap was removed , exposing the underlying connective tissue [ figure 3 ] .
removal of split thickness flap exposed underlying connective tissue margins approximated by sutures patient was prescribed nonsteroidal anti - inflammatory drugs ( diclofenac sodium 50 mg three times daily for 3 days ) and oral antibiotics ( amoxicillin 500 mg three times daily for 5 days ) . patient was instructed to apply ice pack post operatively and minimize lip movement for 1 week .
suture line healed in the form of a scar which was covered by labial mucosa and therefore not visible on smiling [ figure 5 ] .
gingival display at baseline was 5 - 6 mm which changed drastically at 3 and 6 months postoperatively [ figure 6 ] . at 3 month and at 6 months
. however , the lip reverted back to its original position with almost complete relapse after 12 months [ figure 7 ] .
this report aimed to document lip repositioning technique to decrease the amount of gingival display in patients with gummy smile .
the results showed esthetic satisfaction up to 6 months postoperatively after which lip slowly reverted back towards its original position with almost complete relapse at the end of 1 year .
studies have shown that minimal gingival display during smile is considered esthetically acceptable . however , aesthetic perception varies depending on social environment , personal experience and culture .
the amount of gingival display that is considered attractive varies from 1 - 3 mm .
the results showed that the employed surgical procedure successfully reduced the gingival display with low morbidity .
lip repositioning procedure began as a plastic surgical treatment and ever since variations have been reported .
the original technique did not include severing the muscle attachment after flap reflection . however , some authors suggested performing myectomies to detach smile muscle attachment to prevent relapse . another method to prevent reattachment of smile elevator muscles
is the placement of spacer between elevator muscles of lip and anterior nasal spine thereby preventing superior displacement of repositioned lip .
contraindications for lip repositioning surgery include inadequate width of attached gingiva in maxillary anterior sextent .
patients with severe vertical maxillary excess cases are also not the ideal candidates for lip repositioning and should be treated with orthognathic surgery .
silva et al . in 2012 reported successful management of excessive gingival display in a study wherein thirteen patients with excessive gingival display were treated with a modified lip repositioning technique .
treatment consisted of the removal of two strips of mucosa , bilaterally to the maxillary labial frenum and coronal repositioning of the new mucosal margin .
the baseline gingival display of 5.8  2.1 mm significantly decreased to 1.4  1.0 mm at 3 months and was maintained until 6 months ( 1.3  1.6 mm ) .
subjects were satisfied with their smile after surgery and would likely choose to undergo the procedure again ( 92% ) .
similar results were obtained in other case reports by rosenbaltt , simon , and humayun et al . who achieved approximately 4 mm of reduction in gummy smile .
jacobs et al . in 2013 reported a case series where seven patients were successfully managed with trial , and then definitive , lip repositioning wherein a mean reduction in gingival display of 6.4  1.5 mm was achieved .
presented case report of two patients treated with modified lip repositioning technique and obtained significant improvement in the amount of gingival exposure and esthetic satisfaction after a 6 month follow up .
several authors have presented case reports of single patients successfully treated with lip repositioning surgery with a follow up period of 6 months .
this case report shows that although the results of lip repositioning surgery appear stable for up to 6 months postoperatively , its utility as a long term treatment option remains questionable .
more studies with larger sample size and long term follow - up are necessary to establish the level of scientific evidence of this procedure .
however , long - term stability of the results needs to be seen . none the less
, this procedure appears to be a promising alternative treatment option for excessive gingival display .
 excessive gingival display , commonly referred to as  
 gummy smile is a major hurdle in overall personality of an individual . 
 gummy smile , secondary to altered passive eruption and tooth mal - positioning , can be predictably treated with surgery and orthodontic therapy . in patients with jaw deformities , orthognathic surgery can be performed . 
 however , this requires hospitalization and entails significant discomfort . 
 lip repositioning is a simple surgical procedure to treat  
 gummy smile. the procedure restricts the muscle pull of the elevator lip muscles thereby reducing the gingival display while smiling . 
 this procedure is safe and predictable with minimal risk or side effects . 
 this case report describes the successful treatment of excessive gingival display using surgical lip repositioning procedure which can be used as an alternative treatment modality for treatment of excessive gingival display . 
INTRODUCTION
CASE REPORT
Surgical procedure
RESULT
DISCUSSION
CONCLUSION