J Korean Assoc Oral Maxillofac Surg 2021; 47(1): 3~14
Lip repositioning with or without myotomy: a systematic review
Mohammadreza Talebi Ardakani1, Anahita Moscowchi1, Nasrin Keshavarz Valian1, Elham Zakerzadeh2
1Department of Periodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran,
2Private Practice, Tehran, Iran

Anahita Moscowchi
Department of Periodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Daneshjoo Blvd, Evin, Shahid Chamran Highway, Tehran 1983963113, Iran
TEL: +98-21-299-02314
E-mail: a.moscowchi@gmail.com
ORCID: https://orcid.org/0000-0003-1327-5014
Received June 7, 2020; Revised August 22, 2020; Accepted November 2, 2020.; Published online February 28, 2021.
© Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Abstract
Excessive gingival display is an esthetic issue that is commonly managed by different procedures. Lip repositioning is a modality to address concerns of affected patients. The aim of this review was to investigate the scientific evidence on outcomes and long-term stability of lip repositioning surgery with or without myotomy. The electronic search was conducted in three databases: MEDLINE, Embase, and the Cochrane Library up to October 2019. No publication status, language, or time restrictions were applied. The electronic search was complemented by a manual search of the reference lists. Three hundred thirty-eight studies were screened by title, and 16 articles remained for data extraction. The included studies assessed the lip repositioning procedure in 144 patients aged between 15-59 years (134 females and 10 males). Based on the available data, lip repositioning with myotomy/muscle containment can be a successful treatment for minor discrepancies in gingival display in selected cases. However, further well-organized controlled clinical trials are recommended to derive a conclusion about the long-term stability compared with other alternatives.
Keywords: Esthetics, Gingiva, Lip, Dental
I. Introduction

The increasing demand for an attractive smile in the last 40 years has resulted in development of various techniques to respond to patient concerns. Some individuals exhibit excessive gingival display (EGD), which is reported in 7% of in males and 14% of in females, and can impose esthetic issues1. EGD can be classified into four distinct types: continuous band of EGD (type 1), which is the most common type; excessive display of the posterior gingiva (type 2); unilateral (type 3); and EGD in the anterior area (type 4)2. In addition to a high smile line, which is prevalent among 10.57% to 38.9% of individuals1,3, factors including delayed tooth eruption or excessive tooth coverage with gingival tissue, inadequate upper lip movement, upper lip length, and skeletal issues can contribute to this condition4.

In general, the underlying etiology of a gummy smile dictates the primary treatment approach. Such techniques include crown lengthening procedures5, orthodontic leveling of the gingival margins6, maxillary tooth intrusion7, lip repositioning8, orthognathic surgery9, and nonsurgical procedures such as administration of botulinum toxin A10.

Rubinstein and Kostianovsky11 in 1973 described lip repositioning surgery without muscular intervention. This technique is conducted to limit retraction of the upper lip elevator muscles through removal of a strip of mucosa from the maxillary buccal vestibule. More aggressive procedures to increase predictability have been reported with short-term follow-up periods including detachment of labial muscles12, applying a silicone spacer13, lip elongation with rhinoplasty14, and myotomy of the levator labii superioris along with frenectomy8. However, these techniques are not indicated in all cases suffering from gummy smile. Contraindications consist of severe vertical maxillary excess (>8 mm) and the presence of a minimal zone of attached gingiva, which can create difficulties in flap design, stabilization, and suturing15.

Regardless of its gain in popularity, lip repositioning procedures are mainly based on case reports and case series and do not seem to address any points beyond short-term improved outcomes. Furthermore, there has been greater emphasis on the importance of myotomy for long-term stability. Therefore, the aim of this study was to evaluate the available scientific evidence regarding the outcomes and long-term stability of lip repositioning surgery with or without myotomy.

II. Methods

A detailed protocol was developed and followed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement16.

1. Focused questions

PICO question (Participant, Intervention, Comparison, and Outcome):

(1) Participants (P): Patients with EGD

(2) Intervention (I): Lip repositioning surgery along with myotomy or muscle containment

(3) Comparison (C): Lip repositioning surgery alone

(4) Outcomes (O): Amount of improvement in gingival display and stability of the results

The literature was reviewed to answer the following questions:

(1) Does lip repositioning improve esthetics?

(2) Are the results achieved by these techniques stable?

(3) Is there any difference among the various techniques?

2. Search strategy

Two researchers (A.M. and N.K.V.) searched MEDLINE (through PubMed), Embase, and the Cochrane Library (including the Cochrane Central Register of Controlled Trials [CENTRAL]) up to October 2019. The search term ‘lip repositioning’ was utilized to retrieve all relevant studies. We did not limit our search strategy regarding study design, as doing so could have excluded pertinent publications17. No publication status, language, or time restrictions were applied. The electronic search was complemented by a manual search of the reference lists of all relevant articles.

3. Inclusion criteria

Clinical trials including case series and case reports were considered for inclusion. The Cochrane risk of bias tool for randomized trials18 and MINORS (methodological index for nonrandomized studies) were used19 to assess the quality of the studies included in this review.

4. Exclusion criteria

Studies with the following criteria were excluded from the final assessment:

(1) Follow-up duration less than 6 months

(2) Lack of data on preoperative and/or postoperative measurements

5. Study selection and data synthesis

Two authors (M.T.A. and A.M.) independently screened the titles and abstracts based on the inclusion criteria. Full-text articles were obtained in case supplementary data were needed. The extracted data included patient information, preoperative and postoperative gingival display in millimeters at maximum smile, surgical technique, EGD etiology, follow-up period, and complications. Any disagreements during the process were resolved by discussion.

6. Statistical analysis

Standard methods were used to obtain the estimated overall effect size and the corresponding forest plot. All calculations were carried out using Comprehensive Meta-Analysis 2.2.064.

III. Results

The initial search yielded 580 articles: 273 articles through PubMed, 290 through Embase, and 17 articles through the Cochrane Library.(Fig. 1) Manual search resulted in no additional articles. Three hundred thirty-eight studies were screened by title (after elimination of duplicate entries) and 44 articles were considered for full-text assessment. Excluding 28 articles (Table 1)15,20-46, 16 studies remained for data extraction.(Fig. 1) Table 28,47-61 shows the data extracted from these remaining studies.

The risk of bias assessment for non-comparative studies is presented in Table 38,47,48,50,52-61. The risk of bias for one non-randomized comparative study51 was estimated at 23 (of 24) based on the MINORS scoring criteria. The only randomized clinical trial49 was evaluated as “low risk” of bias based on the Cochrane risk of bias tool for randomized trials.

The included studies assessed lip repositioning procedures in 144 patients aged between 15-59 years (134 females and 10 males, not reported in one study with 14 patients50). The most prevalent reported etiology was hypermobile upper lip47,48,50-53,55-57,59,60, followed by altered passive eruption25,28,30,39,47,48,53,57,60, vertical maxillary excess48,56,57, and short upper lip50,51.

All but two studies50,54 used a partial-thickness flap. However, one comparative study reported better results with a full-thickness approach51. Some authors used additional interventions including crown lengthening47,50-53,57,60 and frenectomy8,23,33,37,52,54,57 to achieve more favorable results with higher stability. Alammar et al.51 mentioned two cases with complete relapse in their conventional surgical group. In addition, Dayakar et al.58 reported complete relapse after 12 months, but they did not report additional details.

Six studies provided sufficient data (sample size, mean, and either standard deviation or standard error) to contribute to estimation of the overall effect size for improvement after lip repositioning surgery.(Fig. 2) In five studies, myotomy was performed along with lip repositioning surgery8,49-51,54, while two investigations used sutures to confine the elevator muscles47,52. The analyzed data indicate an improvement of 1.76 mm (95% confidence interval, 1.34-2.18 mm) with myotomy/muscle containment.(Fig. 3) Tawfik et al.49 reported that lip repositioning with myotomy resulted in greater improvement and higher patient satisfaction compared to that without myotomy, which was consistent with the results of another comparative study51.(Fig. 4)

IV. Discussion

Among the procedures used to improve EGD, lip repositioning is a promising alternative. This procedure has been suggested for patients with minor discrepancies requesting a less invasive procedure compared with orthognathic surgery. It also satisfies patients who do not desire to undergo orthodontic therapy or botulinum toxin A administration. This study was conducted to evaluate the current literature regarding the efficacy of myotomy/muscle containment on outcome and long-term stability of lip repositioning surgery.

Most retrieved articles were case series or case reports. The ideal score for non-comparative studies according to MINORS scoring criteria is 16, though none of the chosen studies obtained this. Therefore, the findings should be interpreted with caution.

Among 7 studies involving myotomy/muscle containment, 6 studies8,47,50-52,54 used additional modalities such as crown lengthening and frenectomy. Therefore, it is unclear how much of the improvement is related to lip repositioning surgery alone. One comparative study49 that evaluated the effect of myotomy without other interventions reported better results with the modified technique. However, they did not specify the etiologic contributors for gummy smile in their patients and concluded no clear correlation between etiology and achieved improvement. Studies reported various etiologies for their study population, limiting the ability to draw a conclusion, as vertical maxillary excess48,56,57 can compromise long-term stability15.

Some studies reported subjective improvement without an exact measurement of pre/postoperative gingival display15,20,23,28,37,40. Success must be reported based on measurement of all parameters before and after the procedure to allow exact assessment of the improvement. Consequently, we included studies that reported pre- and postoperative measurements to assess treatment success more accurately. This also applies to patient-related outcome measures (PROMs). Therefore, standardization of the measurement protocol, techniques, outcomes, and PROMs is essential to draw meaningful conclusions.

Tawfik et al.62 published a systematic review in 2018, in which they concluded a persuasive need for randomized and comparative trials to assess the influence of different factors on outcomes, complications, and patient satisfaction. They carried out a randomized clinical trial49 to evaluate the effect of myotomy on lip repositioning results, reporting EGD reduction by 2.73±1.281 mm with classic lip repositioning and greater reduction of 3.57±1.62 mm with myotomy. In another study, Alammar et al.51 compared the conventional technique with the modified approach and demonstrated greater sustainability and less relapse in the modified surgical technique including myotomy. However, they conducted crown lengthening in addition to lip repositioning surgery, which must be considered when interpreting the results.

Based on the available data, lip repositioning can be a successful approach for EGD treatment in carefully selected cases, though it has been shown to have a higher chance of unfavorable results in cases of severe maxillary excess (EGD >8 mm)15. It seems that myotomy/muscle containment can result in better outcomes and stability of the achieved improvement. However, due to the limited number of studies and the discrepancy in the current evidence, further well-organized comparative clinical trials are needed to derive a conclusion regarding the effectiveness of myotomy/muscle containment compared with the conventional approach.

Authors’ Contributions

M.T.A. participated in the study design and data synthesis. A.M. participated in data collection, performed the statistical analysis, and prepared the manuscript draft. N.K.V. and E.Z. participated in data collection. All authors read and approved the final manuscript.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Figures
Fig. 1. Flowchart of the study selection process.
Fig. 2. Forest plot of effect size for lip repositioning without myotomy/muscle containment after 6 months. (Std diff: standard difference, CI: confidence interval)
Fig. 3. Forest plot of effect size for lip repositioning with myotomy/muscle containment after 6 months. (Std diff: standard difference, CI: confidence interval)
Fig. 4. Forest plot of effect size for comparative studies after 6 months. Conventional: Lip repositioning; Modified: Lip repositioning with myotomy/muscle containment. (Std diff: standard difference, CI: confidence interval)
Tables

Articles excluded following full-text assessment

Study Follow-up lessthan 6 months Lack of data on preoperative and/or postoperative measurements Lack of dataon etiology Conflictingdata Studydesign No surgical intervention
Ramesh et al.20 (2019) *
Foudah21 (2019) *
K et al.22 (2018) * *
Faus-Matoses et al.23 (2018) * *
Sharma et al.24 (2017) * *
Sánchez et al.25 (2017) *
Littuma et al.26 (2017) *
Khan et al.27 (2017) *
Gibson and Tatakis28 (2017) *
Farista et al.29 (2017) *
Mahn30 (2016) *
Aly and Hammouda31 (2016) *
Rao et al.32 (2015) *
Muthukumar et al.33 (2015) * *
Bhola et al.34 (2015) *
Storrer et al.35 (2014) * *
Grover et al.36 (2014) *
Gaddale et al.37 (2014) *
Sheth et al.38 (2013) *
Humayun et al.39 (2010) *
Gupta et al.40 (2010) * *
Simon et al.15 (2007) *
Rosenblatt and Simon41 (2006) * *
Ambrosio et al.42 (2018) *
Assenza et al.43 (2011) *
Ergezen et al.44 (2017) *
Mangano and Mangano45 (2013) *
Polo46 (2011) *

Characteristics of the included studies

Study Study design No. of patients Sex Age (yr) Etiology Surgical technique Additional intervention Follow-up duration (mo) Preoperative display (mm) Postoperative display (mm) Complications
Ganesh et al.47 (2019) Case report 1 F 25 1. APE2. HUL Type of instrument: diode laser (940 nm), 400 µm laser tip/continuous mode at 0.8 WLower incision: MGJUpper incision: 10 mmType of incision: partial thicknessMD extension: maxillary premolarSuturing: resorbable (muscle containment)/4-0 silk interruptedRemoved after 14 days 1. Muscle containment2. Crown lengthening: laser gingivectomy 12 7 3 1. Mild pain and tension 1st week2. Minor scar
Torabi et al.48 (2018) Case report 3 2 F1 M 41-54 1. VME2. HUL3. APE Type of instrument: bladeLower incision: MGJUpper incision: labial vestibuleType of incision: partial thickness (periosteal fenestration)MD extension: maxillary 1st molarSuturing: 4-0 silk, 4-0 Vicryl/ suspensory triangular+extraoral stabilization tape N/A 13-16 6.3±4.06 2 months: 0.96±0.736 months: 0.76±0.8713-16 months: 0.72±0.96 N/A
Tawfik et al.49 (2018) RCT Group 1: 20Group 2: 20 18 F2 M N/A Various etiologies Type of instrument: #15 bladeLower incision: MGJUpper incision: 2× the displayType of incision: partial thicknessMD extension: maxillary 1st molarSuturing: 5-0 polyglycolic sutures/continuous & interruptedRemoved after 14 days Myotomy: Group 1 12 Group 1: 6.29±2.6Group 2: 4.31±1.12 Group 1:3 months: 3±1.536 months: 3.42±1.2312 months: 3.57±1.62Group 2:3 months: 1.65±0.906 months: 2.21±1.012 months: 2.73±1.28 1. Pain2. Swelling3. Numbness
Alammar and Heshmeh50 (2018) Case series 14 N/A 18-38 1. SUL2. HUL Type of instrument: bladeLower incision: 1 mm coronal to MGJUpper incision: 10-12 mmType of incision: full thicknessMD extension: maxillary 1st molarSuturing: 4-0 Vicryl (muscle), 3-0 silk (mucosa)/interrupted suturesRemoved after 14 days 1. Myotomy2. Crown lengthening 6 6.36±1.12 1 month: 0.91±1.223 months: 2.27±1.276 months: 2.45±1.13 1. Scar2. Tension in the upper lip3. Minimal discomfort4. Ecchymosis5. Edema6. Flap dehiscence7. Numbness
Alammar et al.51 (2018) PCT 22 19 F3 M 18-38 1. SUL2. HUL (lip mobility >8 mm) Type of instrument: bladeLower incision: 1 mm coronal to MGJUpper incision: 10-12 mmType of incision: partial thickness (Group 1)full thickness (Group 2)MD extension: maxillary 1st molarSuturing: 3-0 silk/interrupted (Group 1) 4-0 Vicryl (muscle), 3-0 silk (mucosa)/ interrupted (Group 2)Removed after 14 days 1. Myotomy (Group 2)2. Crown lengthening 6 5.82±0.87 (Group 1)6.36±1.12(Group 2) Group 1:1 month: 2.18±0.753 months: 2.55±0.936 months: 3.27±0.79Group 2:1 month: 0.91±1.223 months: 2.27±1.276 months: 2.45±1.13 1. Scar2. Tension in the upper lip3. Minimal discomfort4. Ecchymosis5. Edema6. Flap dehiscence7. Numbness
Storrer et al.52 (2017) Case report 1 F 23 HUL Type of instrument: #15C bladeLower incision: MGJUpper incision: N/AType of incision: partial thicknessMD extension: maxillary caninesSuturing: 5-0 nylon/4-0 silk/interrupted external sutures removed after 10 days 1. Muscle containment2. Frenectomy3. Crown lengthening 24 8 2 mm midline4 mm lateral incisors Tension
Mantovani et al.53 (2016) Case report 1 F 23 1. HUL2. APE Type of instrument: N/ALower incision: 1 mm coronal to MGJUpper incision: 10-12 mmType of incision: partial thicknessMD extension: maxillary 1st molarsSuturing: 5-0 polygalactin/continuous interlocking sutures Crown lengthening: 2 mm after lip repositioning 9 5 6 months: 0-1 N/A
Abdullah et al.54 (2014) Case series 12 10 F2 M 20-29 N/A Type of instrument: bladeLower incision: 4-5 mm from gingival marginUpper incision: 8-10 mmType of incision: full thicknessMD extension: maxillary 2nd premolarSuturing: 3-0 Vicryl/interruptedRemoved after 14 days 1. Myotomy2. Frenectomy 12 5±0.95 1 month: 2.66±0.773 months: 3.08±1.166 months: 3.08±1.1612 months:3.08±1.16 1. Feeling of tension2. Mild pain3. Ecchymosis4. Edema5. Complete relapse in 1 patient after 3 months
Ozturan et al.55 (2014) Case series 10 F 22-34 HUL Type of instrument: diode laser (940 nm, 4 W, continuous wave)Lower incision: MGJUpper incision: 10-12 mmType of incision: partial thickness Procedure was done in two stages left/right. MD extension: maxillary 1st molarsSuturing: 5-0 monofilament/continuous interlocking N/A 12 4.3±1.8 6 months: 1.1±1.012 months: 1.2±1.5 N/A
Jananni et al.56 (2014) Case report 1 F 18 1. VME2. HUL Type of instrument: blade #15Lower incision: MGJUpper incision: 2× the displayType of incision: partial thicknessMD extension: maxillary 2nd premolarsSuturing: 4-0 silk/continuous interlocking sutures/periodontal packRemoved after 14 days N/A 18 6 4 N/A
Gabrić Pandurić et al.57 (2014) Case report 1 F 27 1. VME2. HUL3. APE Type of instrument: diode laser (975 μm, 4 W, CW)Lower incision: MGJUpper incision: 1.5× displayType of incision: partial thicknessMD extension: maxillary 1st molarsSuturing: 3-0 silk/interrupted suturesRemoved after 10 days 1. Frenectomy2. Crown lengthening: laser gingivectomy 6 5.5-10 0-2 1. Tension2. Slight pain3. Numbness 1st week4. Scar
Dayakar et al.58 (2014) Case report 1 F 22 N/A Type of instrument: bladeLower incision: MGJUpper incision: 10-12 mmType of incision: partial thicknessMD extension: maxillary 1st molarsSuturing: continuous interlockingRemoved after 14 days N/A 12 5-6 3 months: 36 months: 312 months: complete relapse 1. Mild pain and tension 1st week2. Scar
Silva et al.59 (2013) PCT 13 11 F2 M 19-49 HUL Type of instrument: N/ALower incision: 1 mm coronal to MGJUpper incision: 10-12 mmType of incision: partial thicknessMD extension: maxillary 1st molarSuturing: 4-0 polygalactin/continuous interlocking sutures N/A 6 4-10 (5.8±2.1) 3 months: 0-3 (1.4±1.0)6 months: 0-5 (1.3±1.6) 1. Tension2. Scar
Ribeiro-Júnior et al.60 (2013) Case report 2 F 20-22 1. HUL2. APE(1 patient) Type of instrument: N/ALower incision: 1 mm coronal to MGJUpper incision: 10-12 mmType of incision: partial thicknessMD extension: maxillary 1st molarsSuturing: 4-0 poligalactin/continuous interlocking suturesRemoved after 14 days Crown lengthening: 1 patient 6 76 1 1. Tension 1st week2. Scar
Jacobs and Jacobs61 (2013) Case series 7 F 21-59 N/A Type of instrument: diode laser/#15 bladeLower incision: MGJUpper incision: 2× displayType of incision: partial thicknessMD extension: maxillary 1st molarsSuturing: 3-0 chromic or silk/interrupted or continuous interlocking sutures N/A 1-36 5.36±1.5 1.1±2.5 1. Scar2. Pain, swelling and tension 1st week
Ishida et al.8 (2010) Case series 14 F 15-35 N/A Type of instrument: #15 bladeLower incision: N/AUpper incision: N/AType of incision: N/AMD extension: N/ASuturing: 5-0 resorbable/interrupted 1. Myotomy2. Frenectomy 6-18 5.22±1.48 6 months: 1.91±1.50 N/A

(F: female, M: male, APE: altered passive eruption, HUL: hypermobile upper lip, VME: vertical maxillary excess, SUL: short upper lip, MGJ: mucogingival junction, MD: mesiodistal, N/A: not available, RCT: randomized controlled trial, PCT: prospective clinical trial)


Quality assessment for non-comparative studies

Study Aim Inclusion Data collection Endpoint Evaluation (bias) Follow-up period Loss to follow-up Samplesize Totalscore
Ganesh et al.47 (2019) 2 1 1 2 1 2 2 0 11
Torabi et al.48 (2018) 1 2 1 2 2 2 2 1 13
Alammar and Heshmeh50 (2018) 2 2 2 2 1 1 2 1 13
Storrer et al.52 (2017) 1 1 1 1 1 1 2 0 8
Mantovani et al.53 (2016) 2 1 1 1 0 1 2 0 8
Abdullah et al.54 (2014) 2 2 2 2 2 2 2 1 15
Ozturan et al.55 (2014) 2 2 2 2 2 2 2 1 15
Jananni et al.56 (2014) 0 1 1 1 1 2 2 0 8
Gabrić Pandurić et al.57 (2014) 2 1 2 2 2 2 2 0 13
Dayakar et al.58 (2014) 1 1 1 1 1 2 2 0 9
Silva et al.59 (2013) 2 2 2 2 2 1 2 1 14
Ribeiro-Júnior et al.60 (2013) 2 1 1 1 1 1 2 1 10
Jacobs and Jacobs61 (2013) 2 2 2 2 2 2 2 1 15
Ishida et al.8 (2010) 2 2 2 2 2 2 2 1 15

The items are scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The ideal score is 16 for non-comparative studies and 24 for comparative studies.


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28 February 2021
Vol. 47
No. 1 pp. 1~61

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