Labial Repositioning Using Print Manufactured Polymethylmethacrylate- (PMMA-) Based Cement for Gummy Smile

Treating patients with excessive gingival display (EGD) to provide them with a pleasant smile is a challenge to periodontists. A gummy smile can be due to excessive vertical bone growth, dentoalveolar extrusion, short upper lip, upper lip hyperactivity, or altered passive eruption (APE). In addition, many patients have a lack of lip support due to marked depression of the anterior process of the maxilla. In these cases, lip repositioning using polymethylmethacrylate (PMMA) cement could be performed. This article describes a case of EGD with subnasal depression. In the clinical examination, the presence of a marked subnasal depression was found, in which the upper lip lodged during a spontaneous smile. In addition to this, gingival exposure extending from the maxillary molar on one side of the mouth to the one on the opposite side was also found during the spontaneous smile. Therefore, the periodontal surgical intervention proposed consisted of performing a procedure to fill the subnasal depression with PMMA cement. This article describes a digital approach to plan the use of PMMA cement in lip repositioning in a patient with gummy smile and subnasal depression. The patient reported no postoperative complications. Six months after the surgery, the patient revealed a more harmonious smile than before, with reduction in the gingival exposure and new adequate support for and repositioning of the upper lip.

Gummy Smile Treatment by Aesthetic Crown Lengthening on Altered Passive Eruption Case

An attractive smile enhances the appearance and acceptance of an individual in society. Gum exposure more than 3 mm is generally considered unattractive and known as a gummy smile, which is usually considered an aesthetic problem. At present, patients have a greater desire for more aesthetic results that may influence the planning of dental treatments. This case report aimed to describe the surgical sequence of aesthetic crown lengthening to improve smile profile and eliminate gummy smile. We reported a 21-year-old non-smoking woman with no pertinent medical history who presented with a chief complaint of an unattractive smile due to excessive gingival display. The gingival display in the smile was 5 mm, and the width to height ratio of the central incisor was 121%. Neither periodontal problems nor teeth mobility was detected. Assessment for the condition was excessive gingival display due to altered passive eruption. The overall prognosis for this case was good. The primary treatment plan proposed to the patient was an aesthetic crown lengthening. Altered passive eruption class I subtype A was a case conclusion, and aesthetic crown lengthening with gingivectomy without osseous reduction was the selected treatment. In conclusion, aesthetic crown lengthening should be considered as a surgical component of aesthetic therapy to improve smile profile and eliminate gummy smile.

DIGITAL SMILE DESIGN

Introdução: O planejamento Digital Smile Design (DSD) está cada vez mais sendo usado no ramo odontológico, por suas vantagens e por se caracterizar como um planejamento apurado e detalhado. Este recurso aproxima e melhor a comunicação do profissional com o paciente e vice-versa, sendo de extrema importância para visualizar previamente o resultado final do trabalho, o que dá o privilégio para o paciente, de aprovar ou não a realização do mesmo. Este trabalho tem como objetivo discutir, abordar e conceituar as vantagens do DSD e como ele tem funcionado para a odontologia. Material e Método: É baseado em um estudo de revisão narrativa da literatura, de abordagem qualitativa, utilizado como fonte de evidência a base de dados PubMed. A coleta de dados foi realizada nos meses de agosto e setembro do ano de 2020 utilizando as palavras­chave: “Digital Smile Design”, “periodontal cirurgy”, “Gingivoplasty”, “Smile design”, “Excessive gingival display” e “Gummy smile”. Resultados: O DSD realiza um desenho dentário e mede a altura e largura do mesmo, utiliza linhas complementares com referência que são adicionadas para atingir o desenho de um sorriso esteticamente ideal para determinado indivíduo. Conclusão: O DSD mostrou­se eficaz no planejamento de cirurgias plásticas periodontais, permitindo um planejamento preciso e um resultado prévio do tratamento, podendo o paciente participar ativamente e com mais precisão desta etapa.

Full Digital Surgery-First, Skeletal Anchorage and Aligners Approach to Correct a Gummy Smile and Class II Malocclusion with Mandibular Retrusion and Deviation

Background: The demand for interdisciplinary orthodontic treatment has increased significantly in the past few years, especially in adult patients. This kind of treatment requires careful clinical management, as consequence of the possible complications and limits related to adult age. However, the use of skeletal anchorage and three-dimensional (3D) digital technology has deeply revolutionised diagnostic planning and treatment strategies. Methods: A fully digital approach to the treatment of a Class II patient with a gummy smile and mandibular deficiency and deviation, consisting of initial surgery followed by the use of aligners and skeletal anchorage, is described. Results: The 3D, fully digital pre-evaluation enabled clinicians to accurately and reliably plan the surgical procedure and subsequent orthodontics, including the individualised positioning of stabilisation plates and a splint for maxillary and chin surgical movements. This allowed for the improvement of the patient’s facial aesthetics and dental occlusion without the use of visible orthodontic appliances or the occurrence of pre-surgical aesthetic worsening. Conclusions: This approach could be very effective for adult patients seeking aesthetic treatment options for facial and dental aesthetic improvement.

The Lip Repositioning Surgery: A Review of the Technique's Evolution

The lip repositioning technique (LRT) is considered a safe and predictable gummy smile (GS) treatment. However, since Rubinstein and Kostianovsky introduced it in 1973, it has undergone several modifications. This article aims to review and provide a historical compilation of LRT evolution to help clinicians understand each technique's description and the rationale for its modifications to treat GS.An electronic search was performed in Medline, Scopus, and Cochrane Library up to May 2021 including the terms “lip repositioning,” “lip repositioning technique,” or “lip repositioning surgery” and studies evaluating or discussing the original LRT's modifications in detail. The search had no language or time restrictions. Additionally, a hand-searching of references of all included articles was performed.Modifications described in the literature include muscle severance, subperiosteal dissection of the gingiva, frenectomies, and the use of adjuvant products. They aim to minimize relapse, morbidity, and improve stability. Discomfort, scar formation, and pain were the most frequent complications reported. The choice to use a modification should be analyzed and customized to the individual patient's needs.

Botulinum Toxin A in the Management of a Gummy Smile: A Clinical Controlled Preliminary Study

Background Botulinum toxin-A (BTX-A) is recent technique to treat gummy smile. Objectives This randomized controlled preliminary clinical trial evaluated BTX-A on excessive gingiva display (EGD) reduction, muscle activity, and patient satisfaction at 2, 8, 12, 16, 21, and 25 weeks. Methods Group 1(G1): 4 points of BTX-A application (2U/point) for relaxation of the levatorlabii superioris alaeque nasi (LLSAN) and levatorlabiisuperioris (LLS) muscles; Group 2(G2): Two points of BTX-A (2U/point) for relaxation of the LLSAN muscle. Results A high dropout of patients during some follow-up sessions occurred. So, considering this data limitation, the results found were considered a preliminary outcome. In 2 weeks, there was a significant difference between baseline regarding the reduction of EGD in G1 and G2, reduction in muscle activity in G1, and increased satisfaction in G1 and G2. In 2 weeks, there was no difference between both groups. Statistical EGD reduction was maintained until 16 weeks for G2 and 25 weeks in G1. After 14 days there was a gradual recovery of muscle activity in both groups until baseline values recovery within 25 weeks. Patients' satisfaction with treatment lasted 21 weeks in G1 and 16 weeks in G2. Conclusions Increasing BTX-A injection points resulted in a prolonged effect regarding EGD reduction and patient satisfaction but did not increase the intensity of the outcome. However, due to the high dropout of patients, this is a suggested preliminary conclusion based on available data and more additional studies are necessary to testify the results described.