When One Gum Procedure Is Not Enough

The Patient's Journey

This patient presented with three problems that had developed together over a number of years. Grinding had worn the edges of her upper teeth unevenly, which had tilted the line her smile followed. The two central incisors carried composite bonding placed to repair that wear, and the bonding had discoloured against the natural teeth around it. Her smile also displayed a considerable amount of gingival tissue on full animation.

The gingival display was the finding that determined the sequence of the plan. Excessive gingival display has several possible causes, and they are not interchangeable, so the first task was measurement rather than treatment. The gums may sit low over teeth of normal size, the upper lip may rise further than average when smiling, or the upper jaw may be vertically long. Each of these produces an identical complaint from the patient, and each responds to a different procedure.

Understanding the Challenge

Assessment demonstrated that two of these causes were operating simultaneously. Her gingival margins sat low over teeth that had also been shortened by wear, and her upper lip was hyperactive, rising further on smiling than a normal lip does. A normal upper lip elevates roughly six to eight millimetres; a hyperactive lip rises approximately one and a half times that distance, exposing gum tissue that is otherwise in an ordinary position.

Crown lengthening removes excess gingival tissue and recontours the alveolar bone beneath it, which addresses the gum-and-tooth half of the problem. That procedure has a defined limit. Bone can only be recontoured so far before the support the teeth depend on is compromised, and her gum display exceeded what that procedure could safely correct on its own. Pushing a single procedure past its safe range in order to avoid adding a second one is how teeth end up with less support than they need.

How Dr. Mehdizadeh Approached Treatment

Lip repositioning surgery addresses the second cause directly. A horizontal strip of mucosa is removed from inside the upper lip and the vestibular sulcus is shortened with sutures. This limits how far the elevator muscles can draw the lip during a smile. Published reductions in gingival display following this procedure average approximately three and a half millimetres. The procedure does not touch the teeth or the gum line; it changes how much of them the lip reveals.

Both procedures were carried out in a single surgical stage. Staging them separately would have meant two surgical episodes, two healing periods, and an intermediate state in which neither the gum line nor the lip position was final. The veneer design depends on knowing how much tooth will be visible at full smile. That figure is the product of both variables together rather than either one alone.

Six weeks of healing followed, which allowed the gingival margins to settle and the lip to establish its new range of movement. Temporary veneers were then placed so the restored length and the corrected smile line could be assessed before anything was finalised. Ten upper porcelain veneers were delivered once those positions were agreed.

The Result After Ten Weeks

The gingival display is within a normal range, and it was brought there by two procedures each doing the part it is suited to rather than one doing more than it safely should. The upper lip is fuller at rest, which is a common and expected consequence of the repositioning procedure.

The worn incisal edges have been restored in porcelain. This allowed the smile line to be levelled at the same time, and the discoloured bonding has been replaced with a material that holds its colour. The wear itself was caused by grinding, so the restorations are protected by a night guard and the bite is monitored at recall.

One limitation of the lip procedure should be stated explicitly. The published follow-up on lip repositioning is inconsistent: one 2021 study reported a stable result at three and a half years, another found the change had substantially reversed by six months, and a 2023 series of two hundred patients using a different suturing method reported no recurrence at one year. Case selection and technique appear to matter a great deal. That uncertainty is one reason the gum-side correction was performed as well rather than relying on the lip alone.