The document describes a new surgical technique for treating gummy smiles. The technique involves gingival recontouring combined with traction and containment of the elevator muscle of the upper lip and wing of the nose. The procedure was demonstrated successfully in a human corpse. It was then performed on a 30-year-old female patient with a 7mm gummy smile. After surgery, her smile showed improvement that remained after 12 months. The technique aims to lower the upper lip and smile line for a more aesthetic result, and provides an alternative treatment for gummy smiles.

1. Treatment of gummy smile: Gingival recontouring with the
containment of the elevator muscle of the upper lip and wing of
nose. A surgery innovation technique
INTRODUCTION
There has been a growing demand by patients for esthetic solutions to their smile. Therefore, the
current dentistry, which must be based on scientific evidences, has been searching for
alternatives and new techniques on a regular and evolutionary basis.
Periodontics is a branch of dentistry that searches for solutions in the construction of the facial
esthetics, in which the harmony between lips, teeth and gums is extremely important. Lips define
the esthetic zone of what is considered a smile frame.[1] According to the literature, some
aspects should be observed in order to rate each patient's type of smile. The excessive gingival
display when a patient smiles (from 4 mm or more), known as gummy smile, along with a short
clinical crown of the maxillary anterior teeth characterize esthetic problems.[2] There are
different etiologies of gummy smile, such as: Excessive vertical bone growth, dentoalveolar
extrusion, short upper lip, upper lip hyperactivity, altered passive eruption and the combination
of some of these factors.[1,3] There is an adequate treatment for each kind of etiology, and two
or more techniques can be associated.
When gummy smile is caused by excessive gingival tissue partially covering the anatomical
crown of the teeth (which is also caused by altered passive eruption), a resective gingival surgery
(gingivoplasty) is recommended.[4] Thus, a surgical technique to position the gingival margin
more apically should be planned, without exposing the root surface, observing the amount of
keratinized gingiva and the relationship between the cement - enamel junction, the gingival
margin and the alveolar bone crest.[5,6] However, some cases are not solved only through
gingival recontouring (GR) because the amount of gingival display on smile is still significant.
In search of a more satisfactory result and a more harmonious smile, this study proposes to
demonstrate a new surgical technique with the combination of GR + the traction and containment
surgery of the elevator muscle of upper lip and wing of nose (EMULWN).
Such a technique requires the knowledge of anatomy, location and insertions of the EMULWN.
In the literature, this muscle is described as being long and slender, extending from the frontal
process of the maxilla at the level of the eye's angle up to the upper lip. Before it is inserted in
the lip, the muscle sends fibers to the wing of the nose skin. Then, it is divided into medial and
lateral cords; the lateral cord raises and everts the upper lip and raises, deepens and increases the
curvature of the upper part of the nasolabial groove. The medial cord pulls the lateral branch
superiorly, displaces the circumalar groove laterally and changes its curvature: It is a dilator of
the nostrils.[7] In the technique described, only the lateral bundle of the muscle was pulled and
then contained. This surgical technique was first demonstrated in a corpse from the Miami
Anatomical Research Center (MARC) [Figures [Figures11--4].4]. This technique is considered a
surgical innovation and has not been reported in the scientific literature yet.

2. Figure 1
Photo illustrating the vestibule of the upper arch in a human corpse (MARC). Anatomical details of the
anterior third of the arch (keratinized gingiva and alveolar mucosa). Vertical incision on the labial frenum
and horizontal incisions on a superficial layer of the mucogingival line up to the height of the canines

3. Figure 4
Sutures made with a 4-0 silk thread in the horizontal incisions and in the vertical incision on the labial
frenum
Figure 2
Image after the divulsion and separation of the external epithelium from the mucosa with the use of
Goldman-Fox scissors, exposing and pulling the lateral bundle of the elevator muscle of the upper lip and
wing of nose bilaterally

4. Figure 3
Containment of the muscle bundles with an absorbable suture thread in the highest portion of the inserted
gingiva on both sides
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CASE REPORT
Patient CM, a 30-year-old female, came to the Clinic of Specialty in Periodontics at Positivo
University relating her dissatisfaction with her smile after the removal of a fixed orthodontic
appliance, which she had worn for 2 years. On clinical examination, it was found that her
periodontal condition was satisfactory, but she wanted to improve the esthetics of her smile
because it “showed too much of her gum” [Figure 5]. It was observed that, after the analysis of
her facial thirds, which looked increased, the patient had too much gingival display while
smiling, an extreme case of gummy smile measuring 7 mm from the gingival margin to the lower
border of the upper lip [Figure 6].

5. Figure 5
Initial photo of the smile before the surgery

6. Figure 6
Measurement of the gummy smile, with the help of a periodontal probe, with 7 mm of gingival display
A probing clinical depth with an average of 3 mm from the anterior teeth up to the second right
and left maxillary premolars was detected through the use of a periodontal probe. The GR
technique was an option given to the patient in order to eliminate these 3 mm. To soften the
image of the remaining 4 mm-gum display when the patient smiled, a releasing technique to
contain bilaterally the elevator muscle of upper lip and wing of the nose was chosen.
Firstly, the technique of GR was used under the effect of an infiltrative infraorbital anesthesia on
both sides of the upper arch. The gingival groove was fully measured and marked in its
maximum depths through the use of a periodontal probe in order to identify the homogeneity of
the probing values. Afterwards, a superficial delimitation joining the markings previously made
was made with a scalpel blade 15. These markings were deepened with the same blade in an
internally beveled incision. In addition, intrasulcular incisions were made in order to remove the
gingival tissue that partially covered the anatomical crown of the teeth. A slight elevation of the
flap was made with a Molt Periosteal Elevator and the flap was kept in the keratinized gingiva in
order to loosen the fibers and avoid the recurrence of the gingival margin on the crown of the
teeth. The upper part of the inserted gingiva was fully preserved in order to support the sutures,
which will contain the elevator muscle of upper lip and wing of nose. Some suspensory sutures
were made after the repositioning of the flap [Figures [Figures77--1010].
Figure 7
Markings of the depth of gingival sulcus with a periodontal probe or a Crane Kaplan probe. Union of
these markings with an internal bevel incision

7. Figure 10
Continuous suture made with a 4-0 silk thread on the labial frenum and in between the mucosa and the
keratinized gingiva

8. Figure 8
The excess of gingival tissue is removed with the use of an Orban knife. Note the significant increase of
the dental crowns
Figure 9
Traction of the elevator muscle of the upper lip and wing of nose with an absorbable suture thread.
Sutures in a deep layer between the muscle and the upper portion of the keratinized gingiva
Subsequently, a vertical incision was made on the labial frenum and two more horizontal
incisions were made on the mucogingival line, starting from the frenum incision up to the height
of the canines. The flap was carefully divulsed with Goldman Fox scissors and also a curved
hemostat, separating the external epithelium from the muscle bundle mucosa, on both sides, at
the height of the lateral incisors and canines. With an absorbable suture thread, the elevator
muscle of upper lip and wing of nose was pulled downwards, repositioning its bundle nearer the
highest portion of the keratinized gingiva. Simple sutures were made, as many as necessary, in
order to contain the pulled muscle in this position. The procedure ended up with a continuous
suture in the labial frenum and in the horizontal incisions with the use of a 4-0 silk suture thread.
The external stitches should be removed in 10-15 days’ time [Figure 11].

9. Figure 11
After 12 months of post-operative control. The patient's lip was repositioned closer to the teeth. It was
brought down to show less gingiva
The esthetics of the smile showed an improvement at just 13 days post-surgery. This esthetic
result remained for a 12-month follow-up [Figure 12].

10. Figure 12
View profile after 12 months of post-operative control. The patient's lip was still closer to the teeth. She
can smile with confidence
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DISCUSSION
The present study demonstrated a new surgical technique with the combination of GR + the
traction and containment surgery of the EMULWN. The objective was to reduce the shortening
of the upper lip and, therefore, the lowering of the smile line toward a more esthetic height.
Through a simple ambulatory procedure, under local anesthesia, excellent results were achieved.
As a result of the socio-economic development, the expectations of patients searching for
esthetic treatments have undoubtedly become a challenging goal, especially because such
expectations are often created from famous people's esthetic standards. Esthetic principles do not
only follow dental parameters but also gingival parameters, and the ideal result is the integration
of these factors with the person's face and smile.[8]
It is important to assess the patients’ expectation and understanding of the possible therapeutic
solutions as the result of such a treatment plan may not meet their expectation.
In cases of a high or gummy smile, some cosmetic procedures are available and began to be
studied in patients with facial paralysis since 1973. The technique described confronts existing
techniques such as silicon implants on the bottom of the vestibule at the base of the anterior nasal
spine, the infiltration of the botulinum toxin A and the resective procedures in the muscles that

11. are responsible for the upper lip mobility; these techniques also have favorable esthetic
results.[9,10]
More recently, a lip repositioning surgery technique aimed to treat the excessive gingival
display, removing a strip of outlined mucosa by a superficial split thickness dissection, leaving
the connective tissue exposed. This procedure obtained 80% average reduction in gingival
display considering only 6 months of follow-up.[11] In the present study, the esthetic result
remained for a 12-month follow-up. Also, the elevator muscle of the upper lip and wing of nose
is pulled downwards, repositioning its bundle nearer the highest portion of the keratinized
gingiva, avoiding shortening of the vermillion length and mucocele formation.
As the nasolabial musculature greatly influences the harmony and the smile esthetics, some
authors, who have been researching it, reported the connection between the nasal septum muscle
and the excessive upper lip lifting, operating on this muscle through a plastic surgery technique
of containment, resulting in a visible reduction in the gummy smile.[12] The technique reported
in this article demonstrates that the containment of a muscle bilaterally is more efficient than the
simple containment of the septum nasal depressor muscle, which is located in the center of the
upper lip, resulting in better upper lip lowering. Furthermore, the containment of the muscle can
be carried out on just one side, correcting the cases of asymmetrical upper lip, when a patient
lifts one side of the upper lip more than the other side while smiling.
The authors also agree with Ishida et al.[13] that once the myotomy allows the muscle to reunite,
the repositioning of the upper lip in a lower situation turns this muscle into a longer one. One of
the objectives of this approach is to maintain the muscular action, as opposed to the injection of
botulinum toxin type A. When the botulinum toxin is used, the septum nasal depressor muscle is
paralyzed; however, this technique has its drawbacks such as limited time of action and an
undesired muscular blocking that can possibly cause unaesthetic effects.[10] The surgical
technique presented here may have a more traumatic post-operative period, but the result of it is
undoubtedly more durable and esthetic. This specific case clearly showed satisfactory esthetic
results, which, besides lowering the upper lip, provided the containment of it, preventing its
eversion and keeping its original width when the patient smiled.
The present study proposed to demonstrate a new surgical technique with the combination of GR
+ the traction and containment surgery of the EMULWN.
It appears that the treatment modality (myotomy) proposed by Ishida et al.[13] provides similar
benefits in terms of gingival display reduction. However, the surgery of rhinoplasties is a much
more aggressive approach with irreversible outcomes and greater potential post-operative
morbidity, such as paresthesia.[11,14] Also, dentists can easily perform the technique presented
here with an intraoral access.
The present study aimed to reduce the shortening of the upper lip and, therefore, the lowering of
the smile line toward a more esthetic height. Through a simple ambulatory procedure, under
local anesthesia, excellent results were achieved.
Regardless of the fact that gummy smile has many causes, this technique represents another
therapeutic option in order for patients to obtain a more harmonious and natural smile. However,
the patient needs follow-up for some years so that any risk of recurrence can be assessed,

12. especially in cases of upper lip hyperactivity. Thus, the containment surgery of the EMULWN
may prove to be a successful esthetic alternative.
The esthetics is part of the current dentistry; therefore, it is crucial to work in full knowledge of
the biological principles that guide it in order to harmonize face and smile as well as maintaining
periodontal health through the control of biofilm and the attention to a supportive periodontal
therapy.
The containment surgery of the muscle of upper lip and wing of nose should be considered as a
possible treatment for gummy smile, and when this treatment is used in association with GR and
other restorative treatments, the outcome is excellence in smile esthetics. It is necessary,
however, to carry out a long-term follow-up of these cases in order to establish the effectiveness
of this treatment in maintaining the height of the smile line for a long time.
Original Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239760/
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