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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘gummy smile surgery’

Case Study: Soft Tissue Correction Of The Gummy Smile

Sunday, July 17th, 2011

Background:  The gummy smile is when excessive soft tissue (attached gingiva) is shown during upper lip animation. Ideally, when more than 1mm of gingival shows it is deemed aesthetically excessive although it probably is only bothersome to most people when it is more than 2 or 3mms. The cause of almost all gummy smiles is vertical maxillary excess, the maxilla is too vertically long for the amount of lip tissue.  

In many gummy smile patients, the maxilla is not long enough to justify a LeFort I or maxillary impaction. Only when the amount of gingival show exceeds more than about 7mms can bone shortening be worth the effort. This leaves a large number of patients to seek out a potential soft tissue or upper lip lengthening approach.

Lengthening the upper lip is a lot more difficult to achieve than shortening it. The upper lip is a suspended structure but the effects of smiling and scar contracture work against any lengthening effort. This requires that all factors that contribute to the upper lip anatomy must be managed during any upper lip lengthening effort.   

Case Study: This 23 year-old female had long been bothered by how much gum she showed when smiling. She had a very broad smile width and the upper lip pulled high up against the face of the maxilla. At maximum smile, the amount of exposed gingival was 9mms. She had an excellent Class I occlusion so the thought of vertical maxillary shortening was understandable not acceptable. The expectation with any soft tissue lengthening procedure was to decrease the amount of gummy smile by half.

Under local anesthesia (infraorbital nerve blocks) supplemented with some IV sedation, a large v-shaped mucosal flap was incised and raised on the inside of the upper lip. One of the levator muscles of the upper lip (quadratus superior nasi) was transected across the base of the nose with this exposure on each side. The v-shaped flap was then advanced and closed in a V-Y pattern to create internal lengthening and increased vermilion fullness. An excision of upper lip mucosa and mucoperiosteum on the face of the maxilla was then done to create a vestibular shortening effect as well.

At six weeks after surgery, all upper lip swelling was gone and the patient had a stable result. She had achieved a 7mm reduction in exposed gingiva with unrestricted and natural movement of the upper lip.

The best result for soft tissue correction of the gummy smile addresses three parts of the upper lip anatomy. The internal mucosa of the upper lip is increased with a V-Y flap. The central upper lip elevator muscle is transected to partially deanimate upper lip movement. The depth of the upper lip vestibule is shortened to help resist upward scar contracture.

Case Highlights:

1) Soft tissue correction of the gummy smile can be done when the maxilla is not excessively long as demonstrated by lip competence at rest. The gummy smile is apparent with smiling.

2) Upper lip lengthening can be accomplished by a V-Y mucosal advancement, levator muscle transection and vestibular shortening.

3) Some relapse should be expected after surgery which stabilizes by six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Soft Tissue Approaches to Treatment of the Gummy Smile

Sunday, August 22nd, 2010

Sitting a close second behind that of one’s eyes, the smile is the face’s greatest expression of emotion. The movement of the upper lip in a smile exposes the underlying teeth which plays a role in how attractive that smile appears. While the teeth are exposed in a smile, the gum tissue usually is not. When more than a little gum tissue appears between the upper lip and the teeth, it becomes known as the gummy smile.

The gummy smile is historically defined as more than 2mms of gum (gingival) show during a smile. The amount of gum show is a function of several factors including the height of one’s incisor teeth, the vertical length of the upper jaw and how much the upper lip moves up during smiling. As a result, there are different types of gummy smiles. Exceeding large gummy smiles (greater than 6 to 8mms of gum show) are primarily a bone-based problem. (length of the maxillary bone) Smaller amounts (2 to 4mms) are often more soft-based. (lip thickness and movement)

Treatments for the gummy smile are far from established or standard. Even though very large gummy smiles are best treated by a maxillary impaction (LeFort 1 osteotomy), that option requires a commitment of a course of orthodontics and a significant surgical procedure. In gummy smiles less than 6mms, most patients will be resistant to such a ‘drastic’ approach.

Soft tissue management of the gummy smile has been based on two goals; to diminish how far the upper lip moves (muscle weakening and/or release) and techniques to bring the upper lip down. (lengthen vertically) The combination of both approaches is really needed to make a significant difference in the appearance of the gummy smile. Neither approach alone has been shown to be effective long-term.

One of the primary upper lip elevators is the levator labii superioris. From its origin below the lower rim of the eye socket to its insertion into the underside of the skin of the upper lip, this vertical strip of muscle runs just outside of the nostril. Severing this muscle can be done from an incision inside the nostril and does weaken upper lip excursion. (as has been shown by Botox injections) But keeping the muscle ends from healing and returning to normal excursion requires something else. This is where the role of the spacer has been shown to be effective. Using a premaxillary implant after muscle release can help the muscle ends from healing back together again. At the least, this spacer helps push the upper lip down. While advocates for this spacer in the past have used synthetic materials, I prefer the use of rolled allogeneic dermis. It is soft, can not be felt like an implant, and will integrate naturally into the surrounding tissues. This is a better way to introduce scar between the muscle ends without risk of long-term complications.

The other component of soft tissue management is upper lip release and lengthening. The upper lip can be released from the inside and its attachments freed up from the bone along the pyriform aperture to the canine fossa. By making the initial incision vertically through release of  the maxillary frenum, such released upper lip tissue can be put back together in a classic V-Y closure pattern which will provide some upper lip length from the inside. When combined with a levator myotomy and spacer, realistic gains in upper lip length and decrease in gingival show can be anywhere from 2 to 6mms.

Such soft tissue gummy smile reconstruction can be done as an outpatient procedure under IV sedation in a simple one hour procedure. While it could also be performed under local anesthesia, patient comfort is better under some a little sedation. There will be some considerable swelling of the upper lip which returns to normal in about 10 days. The upper lip will move a little unnaturally for a few weeks after surgery. While the amount of gummy smile reduction will vary per patient, there are no long-term risks or deformity than can occur from this approach.   

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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