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A gummy smile can negatively affect a patient's self-confidence and satisfaction with their appearance, leading many individuals to seek effective esthetic solutions. The etiology of this condition varies and may include vertical maxillary excess, short upper lip, hyperactive upper lip, gingival enlargement, or altered passive eruption.
Lip Repositioning Surgery is one of the minimally invasive esthetic surgical procedures used to reduce the amount of gingival display during smiling. Despite its effectiveness, this surgery may be associated with challenges such as pain, swelling, delayed wound healing, and the possibility of postoperative relapse over time, which could compromise both esthetic and functional outcomes.
To overcome these challenges and enhance surgical outcomes, adjunctive techniques have been introduced to promote healing and determine whether enhancing the biological healing process can reduce the rate of relapse after LRS. Among the most prominent of these are Injectable Platelet-Rich Fibrin (i-PRF) and Low-Level Laser Therapy (LLLT).
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Liquid Platelet-Rich Fibrin group | Experimental | This group will consist of 11 patients presenting with excessive gingival display due to upper lip hypermobility. Each patient will undergo lip repositioning surgery, followed by immediate injection of Liquid Platelet-Rich Fibrin after completion of the surgical procedure. |
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| Low-Level Laser group | Experimental | This group will consist of 11 patients presenting with excessive gingival display due to upper lip hypermobility. Each patient will undergo lip repositioning surgery, followed by immediate application of low-level laser therapy (LLLT) after completion of the surgical procedure and at 3,7,10, and 14 days after surgery. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Liquid Platelet-Rich Fibrin group | Other | A partial thickness elliptical mucogingival incision was made from the mesial of the central incisor to the mesial of the first molar bilaterally with preservation of the frenulum; vertical height set to twice the excessive gingival display (2:1 ratio), lower margin 1 mm coronal to the mucogingival junction. Epithelium elevated to expose connective tissue (preserving minor salivary glands). Periosteal sutures (4-0 Vicryl, 2-3 per side) placed where connective tissue ≥0.5 mm ; incision edges approximated with simple interrupted 4-0 silk sutures. 20 mL blood collected into additive-free plastic tubes and centrifuged at 300 × g for 5 minutes. The Liquid Platelet-Rich Fibrin layer was aspirated and injected immediately after surgery along incision margins and surrounding tissue at 1 mm depth, multiple points 2-3 mm apart (≈0.1 mL per injection) to achieve homogeneous distribution. |
| Measure | Description | Time Frame |
|---|---|---|
| Gingival display (mm) | Measured in millimeters from the lowest point of the upper lip vermilion border to the free gingival margin of the maxillary teeth (from right second premolar to left second premolar) during full smile. | Baseline and 1, 3 and 6 months postoperatively |
| Wound Healing Index | Wound healing will be assessed using the Wound Healing Index (Huang, Neiva, and Wang, 2005). This is a categorical scale with scores ranging from 1 to 3:
Higher scores indicate better healing outcomes. | weekly for 4 weeks postoperatively |
| Measure | Description | Time Frame |
|---|---|---|
| Postoperative Pain (VAS 0-100) | Postoperative pain assessed using patient self-reported Visual Analogue Scale (VAS, 0-100), where 0 indicates no pain and 100 indicates worst possible pain. Pain will be recorded daily for the first 7 days after surgery. | Days 1-7 postoperatively |
| Postoperative Edema/Swelling |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Tarek Qasem, DDS MSc PhD | Contact | +963 933432778 | Tarek2.qasem@damascusuniversity.edu.sy | |
| Walaa albarry, DDS | Contact | +963 996766302 | walaa9.albarry.@damascusuniversity.edu.sy |
| Name | Affiliation | Role |
|---|---|---|
| Tarek Qasem, DDS MSc PhD | Faculty of Dentistry, Damascus university, Syria. | Study Director |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Faculty of Dentistry, Damascus university , Syria. | Recruiting | Damascus | Rif-dimashq Governorate | Syria |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 38037213 | Background | Miron RJ, Gruber R, Farshidfar N, Sculean A, Zhang Y. Ten years of injectable platelet-rich fibrin. Periodontol 2000. 2024 Feb;94(1):92-113. doi: 10.1111/prd.12538. Epub 2023 Nov 30. | |
| 30412347 | Background | Alammar A, Heshmeh O, Mounajjed R, Goodson M, Hamadah O. A comparison between modified and conventional surgical techniques for surgical lip repositioning in the management of the gummy smile. J Esthet Restor Dent. 2018 Nov;30(6):523-531. doi: 10.1111/jerd.12433. Epub 2018 Nov 9. |
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Randomized comparative clinical trial with blinded outcome assessment. Outcome assessment was performed by an independent examiner who was blinded to the treatment allocation. Clinical photographs and clinical measurements were coded and evaluated without revealing the group assignment. Statistical analysis was performed using coded data to ensure blinding of the data analyst.
|
| low-level laser group | Other | A partial thickness elliptical mucogingival incision was made from the mesial of the central incisor to the mesial of the first molar bilaterally with preservation of the frenulum; vertical height set to twice the excessive gingival display (2:1 ratio), lower margin 1 mm coronal to the mucogingival junction. Epithelium elevated to expose connective tissue (preserving minor salivary glands). Periosteal sutures (4-0 Vicryl, 2-3 per side) placed where connective tissue ≥0.5 mm to ; incision edges approximated with simple interrupted 4-0 silk sutures. low-level laser applied to the surgical site (635nm, 200 mW) as part of the post-surgical treatment and at 3,7,10, and 14 days after surgery. |
|
Postoperative edema/swelling assessed on the third day after surgery using a clinician-reported rating scale: 0 = no visible oedema;
|
| Day 3 postoperatively |
| Esthetic Satisfaction (VAS 0-100) | Esthetic satisfaction assessed using patient self-reported Visual Analogue Scale (VAS, 0-100), where 0 indicates completely dissatisfied and 100 indicates completely satisfied. Evaluation will be performed 6 months postoperatively. | 6 months postoperatively |
| Upper Lip External Length | Measured from the base of the nose to the lower edge of the vermilion border of the upper lip, assessed at both resting and maximum smiling positions | Baseline, 1,3 and 6 months postoperatively |
| Upper Lip Internal Length | Measured at rest and smile to assess the dimensions of the internal upper lip | Baseline, 1, 3 and 6 months postoperatively |
| Intraoperative complications | Any complication during the surgery will be recorded for reporting. A score of 0 will be assigned when none of complications are observed, whereas a score of 1 will be assigned if any complication occurs. | During surgery |
| Post-operative complications | Any complication related to the surgical intervention and healing following the surgical treatment such as infection, or sensory disturbances will be recorded for reporting. A score of 0 will be assigned when none of these complications are observed, whereas a score of 1 will be assigned if any of them occur. | First week postoperatively |
| 40125556 | Background | Farshidfar N, Amiri MA, Estrin NE, Ahmad P, Sculean A, Zhang Y, Miron RJ. Platelet-rich plasma (PRP) versus injectable platelet-rich fibrin (i-PRF): A systematic review across all fields of medicine. Periodontol 2000. 2025 Mar 24. doi: 10.1111/prd.12626. Online ahead of print. |
| 15464564 | Background | Sun G, Tuner J. Low-level laser therapy in dentistry. Dent Clin North Am. 2004 Oct;48(4):1061-76, viii. doi: 10.1016/j.cden.2004.05.004. |
| 29193632 | Background | Tawfik OK, El-Nahass HE, Shipman P, Looney SW, Cutler CW, Brunner M. Lip repositioning for the treatment of excess gingival display: A systematic review. J Esthet Restor Dent. 2018 Mar;30(2):101-112. doi: 10.1111/jerd.12352. Epub 2017 Nov 27. |
| 36832213 | Background | AlJasser RN. A Modified Approach in Lip Repositioning Surgery for Excessive Gingival Display to Minimize Post-Surgical Relapse: A Randomized Controlled Clinical Trial. Diagnostics (Basel). 2023 Feb 14;13(4):716. doi: 10.3390/diagnostics13040716. |
| 6583388 | Background | Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984 Jan;51(1):24-8. doi: 10.1016/s0022-3913(84)80097-9. |
| 10321231 | Background | Robbins JW. Differential diagnosis and treatment of excess gingival display. Pract Periodontics Aesthet Dent. 1999 Mar;11(2):265-72; quiz 273. |