**4. Case**

A young female patient referred complaining that she does not like her smile. On examination the patient was presented an option of orthodontic treatment to adjust the spaces and dental relation before any final restorative esthetic procedures. However, the patient did not prefer any orthodontic intervention. Hence, the cosmetic restorative team evaluated the patient for possible prosthetic rehabilitation of the smile and anterior teeth via dental veneers. Proper examination, impression and lab simulation using wax up models was performed and showed a favorable outcome. Therefore, the team elected to proceed with the treatment. Although the team advised the patient to receive restorative therapy of the premolar teeth, the patient refused, as she was mainly interested in betterment of the anterior tooth show (Figure 2).

**Facial character:** The overall shape, color, and harmony of the face and maxillomandibular relationship should be evaluated clinically as well as radiologically. Clinical pictures of the frontal and profile views from different angles are necessary for documentation. Static evaluation as well as dynamic evaluation of the facial expression is important and any facial asymmetry should not go unforeseen. [2, 7, 8]

Beside the clinical examination of the head and neck region, radiographic evaluation is important to investigate the maxillomandibular complex, temporomandibular joint, and dentition using panoramic radiography and cephalometrics. [5, 7, 8]

*Figure 2: The left picture is showing a moderate smile lip line, with unfavorable dentogengival relation and dental esthetic. The right figure is showing the postoperative results after treatment with restorative veneers at the anterior incisor* **Figure 2.** (Left) a moderate smile lip line, with unfavorable dento-gingival relationship and dental esthetics. (Right) Postoperative results after treatment with restorative veneers (Courtesy of Professor Motaz Ghulman, King Abdulaziz University).

*complain was her anterior incisors. (with Courtesy of Professor Motaz Ghulman, King*

#### **4.1. Principles of managing an unpleasant smile** *teeth. The patient refused extending the veneers into the premolars as her main chief*

Unpleasant smiles can be due to clear defect in one or more of the major smile components, lack of harmony of the smile pillars, or loss of self-satisfaction, which can be due either to a specific demand the patient is requesting (such as cheek dimples) or pure personal psycho‐ logical dissatisfaction. The most important principle in managing such patients is to diagnose the etiology to see if it is actually an organic anatomical issue or is it an issue of self-concept. The answer is usually explored via careful teamwork consultation that will help guide the patient to the proper treatment channels. *Abdulaziz University)* D‐ Facial character: total shape, color, and harmony of the face and maxillomandibular relation. The evaluation is accomplished in clinical as well as radiological evaluation. Clinical pictures to the frontal and side views in different angles are necessary for documentation. While, Static evaluation as well as 

#### *4.1.1. The use of botox and fillers for smiles: [9, 10]* dynamic evaluation of the facial expression are important not to miss any pitfalls in dynamic related facial asymmetry. (2,7,8)

Botox (Botulinum toxin) is a neurotoxin that is derived from the bacterium Clostridium Botulinum that has several serologically distinct subtypes, A, B, C, D, E, and G. It acts by blocking acetylcholine release at the neuromuscular junction, and hence preventing muscular contraction leading to smoothening of the hyperkinetic unpleasant looking facial rhytids or skin lines. The most common one is Botulinum A, Botox. [9, 10] Beside the clinical examination of the head and neck region, radiographic evaluation is important to investigate the maxillomandibular complex, temporomandibular joint, and dentition, through panoramic radiograph and cephalometrics (5,7,8). 

Botox has many applications in medical fields such as: ‐ **PRINCINPLES OF MANAGING UNPLESANT SMILE**


once the dental smile arc line is upturned posteriorly it will reflect better cosmetic results compared to a flat or downturned arc line. [6] Hence, a defect in a single component or inappropriate harmony between each can provide patients with unpleasant smiles. Therefore it is very critical to diagnose the major contributor to the disharmony and formulate the best

**Smile lip line:** This is divided into high, moderate or low horizontal smile lines according to the magnitude of upper lip coverage of the maxillary anterior teeth when static and smiling. [6] A high lip line refers to a smile showing the maxillary anterior teeth and part of the gingival tissue, while a low lip line shows 0-2mm of the anterior teeth. A high smile line is considered to be a challenging factor when rehabilitating the anterior maxilla. As any defect in the crown or gingival tissue can be disclosed; unlike patients with moderate or low smile lines (Figure 2).

**Dental smile line** (smile arc): This pertains to maxillary teeth from the incisor going along to the 1st molar and describes the best cosmetic relation as evaluated by an expert restorative dentist.[4,6] A smooth transition of dental lines, alignment, shape, and color can provide pleasant smiles. The dental smile line is an imaginary line drawn from the incisal edges of the maxillary anterior teeth and following the upper lip inferior border curvature. It can be flat, upturned, or downturned. These lines do have more fine details that a specialist restorative dentist can analyze. [3, 4, 6] The fine dental line details are beyond the scope of the chapter.

A young female patient referred complaining that she does not like her smile. On examination the patient was presented an option of orthodontic treatment to adjust the spaces and dental relation before any final restorative esthetic procedures. However, the patient did not prefer any orthodontic intervention. Hence, the cosmetic restorative team evaluated the patient for possible prosthetic rehabilitation of the smile and anterior teeth via dental veneers. Proper examination, impression and lab simulation using wax up models was performed and showed a favorable outcome. Therefore, the team elected to proceed with the treatment. Although the team advised the patient to receive restorative therapy of the premolar teeth, the patient refused, as she was mainly interested in betterment of the anterior tooth show (Figure 2).

**Facial character:** The overall shape, color, and harmony of the face and maxillomandibular relationship should be evaluated clinically as well as radiologically. Clinical pictures of the frontal and profile views from different angles are necessary for documentation. Static evaluation as well as dynamic evaluation of the facial expression is important and any facial

Beside the clinical examination of the head and neck region, radiographic evaluation is important to investigate the maxillomandibular complex, temporomandibular joint, and

asymmetry should not go unforeseen. [2, 7, 8]

dentition using panoramic radiography and cephalometrics. [5, 7, 8]

management plan accordingly.

194 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**4. Case**


For smiles with hyperactive muscular complex of the upper lip, Botox can be carefully deposited in the main hyperactive areas to reduce the action and hence to allow better draping of the upper lip complex on the maxillary teeth. [11] **THE USE OF BOTOX AND FILLERS FOR SMILES:** (9,10) 

**The advantages are:** easier application, less invasive, quick procedure, reasonable price, reasonably fast onset, and duration of about 6 months.

**Disadvantages are:** the action may start with fine dropping of the upper lip that patients may perceive as unpleasant, it takes from days to weeks to stabilize, asymmetric smile, uncomfort‐ able injections, requiring re-injection after 6 months to stabilize results. [9, 11]

#### *4.1.2. Case presentation*

A 29-year-old woman complained that she was unsatisfied with her smile and that she had to use her hand to cover her mouth while laughing. On examination it was noticed that she had a hyperactive upper lip muscles, orbicularis oris and elevator labii alaeque nasi. She agreed to start management with a simple non-invasive method such as Botox therapy of the hyperactive areas (Figure 3, 4).

**Figure 3.** A 29-year-old woman with a gummy smile. *Figure 3: a 29 years old lady complained of uncosmetic Gummy smile.*

*Figure 4: The patient after treatment with selective Botox therapy at the* **Figure 4.** The patient after treatment with selective Botox therapy at the hyperactive muscular areas. The pictures showing two pleasant smile poses, as compared to the preoperative smile in Figure 3.

*hyperactive muscular areas. The pictures showing two pleasant smile*

#### *poses, as compared to the preoperative smile in Figure 3.* **4.2. Lefort 1 maxillary surgery**

‐ **LEFORT 1 MAXILLARY SURGERY:** A Le Fort 1 maxilary procedure is a surgical intervention where the maxillary bone is osteotomized in semi‐horizontal plane to disengage it from the cephalic end and allow moving the disengaged part into a more favorable position as dictated in A LeFort 1 maxillary procedure is a surgical intervention where the maxillary bone is osteo‐ tomized in the semi-horizontal plane to disengage it from the cephalic end and allow moving the disengaged part into a more favorable position as dictated in relation to the opposing jaw and thus, improving the general facial harmony. The movement can be accomplished in three

relation to the opposing jaw function and improving the general facial harmony. The 

maxillofacial surgeon trained in the field of orthognathics and facial reconstruction usually performs the procedure (5,12). Preoperative evaluation and consultation with an orthodontist trained in the field is necessary to estimate the defect and treatment planning including a thorough preoperative work up. That usually includes the following: Facial clinical pictures, intraoral pictures, panoramic radiograph, lateral cephalometric radiograph, anteroposterior cephalometric radiogrpah, impressions to develop study casts and mounting casts, and a face bow 

movement can be accomplished in variable three dimension as needed. A 

dimensions as needed. A maxillofacial surgeon trained in the field of orthognathics and facial reconstruction usually performs the procedure [5, 12]. Preoperative evaluation and consulta‐ tion with an orthodontist trained in the field is necessary to estimate the defect and treatment planning including a thorough preoperative work up. This usually includes the following: Facial clinical photographs, intraoral photographs, panoramic radiograph, lateral cephalo‐ metric radiograph, anteroposterior cephalometric radiograph, impressions to develop study casts, mounting casts and a face bow transfer to aid in the cast mounting (Figure 5) [5,12]. Once this is accomplished, a proper data analysis is required for each aspect to develop a preoper‐ ative documented record, a diagnosis, and a provisional plan.

**Figure 5.** Lateral cephalometric radiograph with superimposing face bow transfer is a method to insure proper dentos‐ keletal relation before sending the face bow and impressions to the laboratory.

One of the most common indications is in gummy smile cases due to maxillary vertical excess. The procedure can be more challenging in cases with a short upper lip that contributes to the unpleasant smile complex. The procedure is mainly directed toward reducing the maxillary excess by moving the maxilla in the superior direction, and hence, it improves the smile.

**The advantages** of such a procedure are that it provides a major improvement in the shape of the face and smile.

**The disadvantages are** that it is done under general anesthesia, requires hospitalization, requires prolonged recovery time that can be up to a month (hence usually done during a prolonged vacation), postoperative expectations include swelling, pain, midface paresthesia, difficulty eating, minor changes in nasal shape, and general discomfort. [12, 13]

#### *4.2.1. Case presentation*

**The advantages are:** easier application, less invasive, quick procedure, reasonable price,

**Disadvantages are:** the action may start with fine dropping of the upper lip that patients may perceive as unpleasant, it takes from days to weeks to stabilize, asymmetric smile, uncomfort‐

A 29-year-old woman complained that she was unsatisfied with her smile and that she had to use her hand to cover her mouth while laughing. On examination it was noticed that she had a hyperactive upper lip muscles, orbicularis oris and elevator labii alaeque nasi. She agreed to start management with a simple non-invasive method such as Botox therapy of the hyperactive

able injections, requiring re-injection after 6 months to stabilize results. [9, 11]

**Figure 3.** A 29-year-old woman with a gummy smile. *Figure 3: a 29 years old lady complained of uncosmetic Gummy smile.*

*Figure 4: The patient after treatment with selective Botox therapy at the hyperactive muscular areas. The pictures showing two pleasant smile*

**Figure 4.** The patient after treatment with selective Botox therapy at the hyperactive muscular areas. The pictures

A Le Fort 1 maxilary procedure is a surgical intervention where the maxillary bone is osteotomized in semi‐horizontal plane to disengage it from the cephalic end and allow moving the disengaged part into a more favorable position as dictated in relation to the opposing jaw function and improving the general facial harmony. The 

A LeFort 1 maxillary procedure is a surgical intervention where the maxillary bone is osteo‐ tomized in the semi-horizontal plane to disengage it from the cephalic end and allow moving the disengaged part into a more favorable position as dictated in relation to the opposing jaw and thus, improving the general facial harmony. The movement can be accomplished in three

maxillofacial surgeon trained in the field of orthognathics and facial reconstruction usually performs the procedure (5,12). Preoperative evaluation and consultation with an orthodontist trained in the field is necessary to estimate the defect and treatment planning including a thorough preoperative work up. That usually includes the following: Facial clinical pictures, intraoral pictures, panoramic radiograph, lateral cephalometric radiograph, anteroposterior cephalometric radiogrpah, impressions to develop study casts and mounting casts, and a face bow 

movement can be accomplished in variable three dimension as needed. A 

*poses, as compared to the preoperative smile in Figure 3.*

showing two pleasant smile poses, as compared to the preoperative smile in Figure 3.

‐ **LEFORT 1 MAXILLARY SURGERY:**

**4.2. Lefort 1 maxillary surgery**

reasonably fast onset, and duration of about 6 months.

196 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

*4.1.2. Case presentation*

areas (Figure 3, 4).

A 27-year-old patient with an unpleasant smile and difficulty eating. Clinical and radiograph‐ ic evaluation revealed vertical maxillary excess and mandible deviation. The patient under‐

went multi-team comprehensive consultation and found it best to be treated via orthognathic surgery. LeFort 1 maxillary osteotomy was done to position the maxilla in upward position and correctthe rotation,while themandibleunderwentbilateral sagittal splitosteotomytooptimize *mandible* symmetry and occlusion. The patient still requires final orthodontic treatment (Figure 6). *underwent bilateral sagittal split osteotomy to optimize symmetry and*

*occlusion. The patient will still require the final orthodontic dental treatment.*

*Figure 6: Maxillary vertical excess that required Orthognathic surgery intervention to correct the deformity seen on the left picture. The right picture* **Figure 6.** Maxillary vertical excess that required orthognathic surgery intervention to correct the deformity seen on the left. The right picture shows the postoperative favorable results.

#### **4.3. Upper lip enhancement procedures**

(13,14) 

*shows the postoperative favorable results.*

‐ **UPPER LIP ENHANCEMENT PROCEDURES:** Facial aging is a continuous process that can get accelerated by smoking, sun exposure, or personal genetic predisposition. The loss of elastic fibers and replacement with collagen fibers leads to reduction in skin elasticity and sagging of Facial aging is a continuous process that can be accelerated by smoking, sun exposure, or personal genetic predisposition. The loss of elastic fibers and replacement with collagen fibers leads to reduction in skin elasticity and sagging of the skin complex. Hence, cosmetic proce‐ dures such as facial fillers, lipofillers, chemical peeling, surgical lifting procedures, and laser treatment can optimize the general results. [10-14]

the skin complex. Hence, cosmetic procedures such as facial fillers, lipofillers, chemical peeling, surgical lifting procedures, and Laser treatment can optimize the general results. (10,12,13,14) Other surgical procedures are not as common such as upper lip elongation or Other surgical procedures are not as common such as upper lip elongation or shortening that can treat cases of short upper lip that require some elongation to redrape the maxillary teeth. The upper lip is measured from the subnasal point to upper lip stomion, and has an average of 18-22mm length. [8]

shortening that can treat cases of short upper lip that requires some elongation to redrape the maxillary teeth. The upper lip is measured from the subnasal point to upper lip stomion, and has an average of 18‐22mm (8). While a subnasal upper lip‐lift is a procedure used to shorten a long upper lip and to A subnasal upper lip-lift is a procedure used to shorten a long upper lip and to evert it outward. This will allow more maxillary teeth show, upper lip outward eversion, and hence, a more pleasant youthful smile. It can be designed in a W-lift direction to provide better enhancement of the cupid bow area. The W arms can be designed in asymmetric fashion to manage upper lip asymmetric deformities. [2]

evert it outward. This will allow more maxillary teeth show, upper lip outward eversion, and hence, a more pleasant youthful smile. It can be designed in a W‐lift direction to provide better enhancement of the cupid bow area. The W arms can be The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities [13]. Such lip irregularities can be managed using laser therapy to eliminate superficial folds, or even cut and plan the rotation movements needed (Figure 7). [13, 14]

designed in asymmetric fashion to manage upper lip asymmetric deformities. (2) The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities 

(13). Such lip irregularities can be managed using Laser therapy to eliminate superficial folds, or even cut and plan the rotation movements needed (Figure 7). 

### *4.3.1. Case presentation*

*results were immediately noticed.*

went multi-team comprehensive consultation and found it best to be treated via orthognathic surgery. LeFort 1 maxillary osteotomy was done to position the maxilla in upward position and correctthe rotation,while themandibleunderwentbilateral sagittal splitosteotomytooptimize *mandible* symmetry and occlusion. The patient still requires final orthodontic treatment (Figure 6). *underwent bilateral sagittal split osteotomy to optimize symmetry and occlusion. The patient will still require the final orthodontic dental treatment.*

*Figure 6: Maxillary vertical excess that required Orthognathic surgery*

Facial aging is a continuous process that can get accelerated by smoking, sun exposure, or personal genetic predisposition. The loss of elastic fibers and 

the skin complex. Hence, cosmetic procedures such as facial fillers, lipofillers, 

Other surgical procedures are not as common such as upper lip elongation or shortening that can treat cases of short upper lip that requires some elongation to redrape the maxillary teeth. The upper lip is measured from the subnasal point to 

replacement with collagen fibers leads to reduction in skin elasticity and sagging of 

Facial aging is a continuous process that can be accelerated by smoking, sun exposure, or personal genetic predisposition. The loss of elastic fibers and replacement with collagen fibers leads to reduction in skin elasticity and sagging of the skin complex. Hence, cosmetic proce‐ dures such as facial fillers, lipofillers, chemical peeling, surgical lifting procedures, and laser

chemical peeling, surgical lifting procedures, and Laser treatment can optimize the 

A subnasal upper lip-lift is a procedure used to shorten a long upper lip and to evert it outward. This will allow more maxillary teeth show, upper lip outward eversion, and hence, a more pleasant youthful smile. It can be designed in a W-lift direction to provide better enhancement of the cupid bow area. The W arms can be designed in asymmetric fashion to manage upper

Other surgical procedures are not as common such as upper lip elongation or shortening that can treat cases of short upper lip that require some elongation to redrape the maxillary teeth. The upper lip is measured from the subnasal point to upper lip stomion, and has an average

While a subnasal upper lip‐lift is a procedure used to shorten a long upper lip and to 

The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities [13]. Such lip irregularities can be managed using laser therapy to eliminate superficial folds, or even cut

evert it outward. This will allow more maxillary teeth show, upper lip outward eversion, and hence, a more pleasant youthful smile. It can be designed in a W‐lift direction to provide better enhancement of the cupid bow area. The W arms can be designed in asymmetric fashion to manage upper lip asymmetric deformities. (2) The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities 

(13). Such lip irregularities can be managed using Laser therapy to eliminate superficial folds, or even cut and plan the rotation movements needed (Figure 7). 

*shows the postoperative favorable results.*

left. The right picture shows the postoperative favorable results.

198 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

treatment can optimize the general results. [10-14]

upper lip stomion, and has an average of 18‐22mm (8). 

and plan the rotation movements needed (Figure 7). [13, 14]

‐ **UPPER LIP ENHANCEMENT PROCEDURES:**

**4.3. Upper lip enhancement procedures**

general results. (10,12,13,14) 

lip asymmetric deformities. [2]

of 18-22mm length. [8]

(13,14) 

*intervention to correct the deformity seen on the left picture. The right picture*

**Figure 6.** Maxillary vertical excess that required orthognathic surgery intervention to correct the deformity seen on the

A 23-year-old female referred complaining of unesthetic upper lip and unpleasant smile. The patient had had multiple cleft lip and palate repair procedures in the past. The patient was presented an option of asymmetric upper lip lift and fat transfer to the upper lip. The procedure took place under general anesthesia and the results were immediately noticed (Figure 7, 8). *CASE (Figure 7,8): a 23 years old female was complaining of uncosmetic upper lip and unpleasant smile. The patient had had multiple cleft lip and palate repair procedures in the past. The patient presented an option of asymmetric upper lip lift and fat transfer to the upper lip. The procedure took place under general anesthesia and the*

*The plan surgically was to lift up the upper lip, evert it outward, and augment it using fat transfer. The picture on the right showing the preoperative W‐lift marking. (2)* **Figure 7.** The patient at the preoperative stage (left); the upper lip is thin, inverted and flat. The plan surgically was to lift up the upper lip, evert it outward, and augment it using fat transfer. The picture on the right shows the preopera‐ tive W-lift marking. [2]

*Figure 7: The patient at the preoperative stage; the upper lip is thin, inverted and flat.*

Upper lip volume enhancement can be accomplished using autogenous grafts such as fascia, muscle, and periosteum especially if more volume is needed in compromised sites such as repaired cleft lip with notching or whistle deformity (Figure 9). Synthetic fillers are a common option now days to achieve lip volume enhancement or final border definition [7-9, 13].

#### *4.3.2. Case presentation*

A 34-year-old male patient referred complaining of extramucosal fold of his upper lip that shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy to remove the mucosal folds under local anesthesia (Figure 9).

*complaining of extramucosal fold at his upper lip that shows more during smiling. The patient presented an option of Erbium‐Yag laser therapy to remove the mucosal folds under local aesthesia. The picture on the right showing the result immediately post laser therapy, indicating dry field and a* **Figure 9.** The left picture presents a smile of a 34-year-old male patient complaining of extramucosal fold of his upper lip that shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy to remove the mucosal folds under local anesthesia. The picture on the right showing the result immediately after laser therapy, indi‐ cating the dry field and a potential of favorable secondary intentional healing. *potential of favorable secondary intentional healing.* Upper lip volume enhancement can be accomplished using autogenous grafts such 

*showing the result immediately post laser therapy, indicating dry field and a*

*potential of favorable secondary intentional healing.*

*Figure 9: The left picture presents a smile of a 34 years old male patient*

#### *4.3.3. Case presentation* as fascia, muscle, and periostrium especially if more volume is needed in compromised sites such as repaired cleft lip with notching or whistle deformity

Upper lip volume enhancement can be accomplished using autogenous grafts such as fascia, muscle, and periostrium especially if more volume is needed in compromised sites such as repaired cleft lip with notching or whistle deformity (Figure 10). Synthetic fillers are a common option now days to achieve lip volume enhancement or final border definition (7,8,9,13). A 23-year-old female presented with severe whistle deformity and notching of the upper lip secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision; however, she was not keen to do so. Hence, she was presented the option of periosteummuscular graft augmentation harvest from the lower lip / chin mass and transfer to the upper lip (Figure 10). (Figure 10). Synthetic fillers are a common option now days to achieve lip volume enhancement or final border definition (7,8,9,13). *CASE (Figure 10): the following is a 23 years old lady presented with severe whistle deformity or notching of the upper lip secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision, however, she was not keen to do so. Hence, she was presented the option of periostium‐muscular graft augmentation*

*CASE (Figure 10): the following is a 23 years old lady presented with severe whistle*

*harvest from the lower lip / chin mass and transfer to the upper lip.*

*picture using autologous muscular graft. The Right picture is showing three* **Figure 10.** Reconstruction of an upper lip with severe notch deformity on the left picture using autologous muscular graft. The photograph on the right is three months postoperative. Final fine-tuning of lip boundaries can be achieved using synthetic fillers.

*Figure 10: Reconstruction of an upper lip severe notch deformity on the left*

*Figure 10: Reconstruction of an upper lip severe notch deformity on the left picture using autologous muscular graft. The Right picture is showing three*

#### **4.4. Crown lengthening**

(figures 11). (14) 

*4.3.2. Case presentation*

*4.3.3. Case presentation*

lip (Figure 10).

using synthetic fillers.

A 34-year-old male patient referred complaining of extramucosal fold of his upper lip that shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy

> *Figure 9: The left picture presents a smile of a 34 years old male patient complaining of extramucosal fold at his upper lip that shows more during smiling. The patient presented an option of Erbium‐Yag laser therapy to remove the mucosal folds under local aesthesia. The picture on the right showing the result immediately post laser therapy, indicating dry field and a*

*Figure 9: The left picture presents a smile of a 34 years old male patient complaining of extramucosal fold at his upper lip that shows more during smiling. The patient presented an option of Erbium‐Yag laser therapy to remove the mucosal folds under local aesthesia. The picture on the right showing the result immediately post laser therapy, indicating dry field and a*

**Figure 9.** The left picture presents a smile of a 34-year-old male patient complaining of extramucosal fold of his upper lip that shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy to remove the mucosal folds under local anesthesia. The picture on the right showing the result immediately after laser therapy, indi‐

Upper lip volume enhancement can be accomplished using autogenous grafts such 

Upper lip volume enhancement can be accomplished using autogenous grafts such 

A 23-year-old female presented with severe whistle deformity and notching of the upper lip secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision; however, she was not keen to do so. Hence, she was presented the option of periosteummuscular graft augmentation harvest from the lower lip / chin mass and transfer to the upper

*CASE (Figure 10): the following is a 23 years old lady presented with severe whistle deformity or notching of the upper lip secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision, however, she was not keen to do so. Hence, she was presented the option of periostium‐muscular graft augmentation*

*CASE (Figure 10): the following is a 23 years old lady presented with severe whistle deformity or notching of the upper lip secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision, however, she was not keen to do so. Hence, she was presented the option of periostium‐muscular graft augmentation*

*Figure 10: Reconstruction of an upper lip severe notch deformity on the left picture using autologous muscular graft. The Right picture is showing three*

*Figure 10: Reconstruction of an upper lip severe notch deformity on the left picture using autologous muscular graft. The Right picture is showing three* **Figure 10.** Reconstruction of an upper lip with severe notch deformity on the left picture using autologous muscular graft. The photograph on the right is three months postoperative. Final fine-tuning of lip boundaries can be achieved

as fascia, muscle, and periostrium especially if more volume is needed in compromised sites such as repaired cleft lip with notching or whistle deformity (Figure 10). Synthetic fillers are a common option now days to achieve lip volume 

as fascia, muscle, and periostrium especially if more volume is needed in compromised sites such as repaired cleft lip with notching or whistle deformity (Figure 10). Synthetic fillers are a common option now days to achieve lip volume 

*harvest from the lower lip / chin mass and transfer to the upper lip.*

*harvest from the lower lip / chin mass and transfer to the upper lip.*

*potential of favorable secondary intentional healing.*

*potential of favorable secondary intentional healing.*

enhancement or final border definition (7,8,9,13). 

enhancement or final border definition (7,8,9,13). 

cating the dry field and a potential of favorable secondary intentional healing.

to remove the mucosal folds under local anesthesia (Figure 9).

200 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Crown lengthening is defined as a procedure used to increase the height of the clinical crowns by removing part of the gingival tissue with or without the crestal alveolar bone [14]. The procedure is usually designed according to the demand of the clinical crown height or the planned prosthetic crown or veneer. The tissue ablation is performed using blades, lasers, or less favorably, electrocautery, which has the tendency to damage the soft tissue cuff when compared to laser-based precise cutting capabilities. However, Laser treatment will require a set up to be ready, such as machine position, extensions, wires plastic covers, goggle's for the team and patient, surgical sites protections, and proper infection control protocol (Figure 11). [14]

The dental gingival relation describes the maxillary teeth height, width, shape, and alignment status in relation to the gingival envelope. This can never be satisfying unless it was reflected in a beautiful smile [1, 2]. Therefore, a specialized restorative dentist should evaluate the case to verify the needed consultation and intervention, which can vary from simple odontoplasty, placing veneers, crowns, orthodontic treatment, or even extraction, alveolar bone reconstruc‐ tion and implant-based rehabilitation (Figure 12).[15-17] Hence, teamwork is always the key to reach the best dento-gingival relation to provide a satisfying smile. This can be clarified through two examples, the first one illustrating the role of the oral and maxillofacial surgeon to evaluate a poor alveolar bone supporting the gingival tissue that requires alveolar recon‐ struction in horizontal and/ or vertical dimensions before prosthetic rehabilitation. [17] The second example illustrates the role to manage patients with short lip and vertical maxillary excess that will never be managed properly if crown-lengthening procedure was only performed. Such a case will require a LeFort 1 surgical procedure to reposition the maxilla superiorly first. [5, 12] *months follow up favorable presentation. Final fine‐tuning of lip boundaries can be achieved using synthetic fillers.* ‐ ‐ **CROWNLENGTHNING:** Crown lengthening is defined as a procedure used to increase the height of the clinical crowns by removing part of the gingival tissue with or without the crestal alveolar bone (14). The procedure is usually designed according to the demand of the clinical crown height or the planned prosthetic crown or veneer. The tissue ablation is performed using blades, Lasers, or less favorably; electrocautery, which has the tendency to damage the soft tissue cuff when compared to Laser based precise cutting capabilities. However, Laser treatment will require a set up to be ready, such as machine position, extensions, wires plastic covers, goggle's for the 

team and patient, surgical sites protections, and proper infection control protocol 

**Figure 11.** Showing the laser setup in the dental office as well as surgical site preparation for laser assisted labial freno‐ plasty.

The dental gingival relation describes the maxillary teeth height, width, shape, and alignment status in relation to the gingival envelope. This can never be satisfying unless it was reflected on a beautiful smile (1,2). Therefore, a specialized restorative dentist should evaluate the case to verify the needed consultation and intervention, which can vary from simple odontoplasty, placing veneers, crowns, orthodontic treatment, or even extraction, alveolar bone reconstruction and implants based rehabilitation (Figure 12) (15,16,17). Hence, teamwork is always the key to reach the best dento‐gingival relation to provide a satisfying smile. This can be clarified through two examples, the first one illustrating the role of oral maxillofacial surgeon to evaluate a poor alveolar bone supporting the gingival tissue that requires alveolar 

reconstruction in horizontal and/ or vertical dimension before prosthetic 

rehabilitation (17). The second example illustrates the role to manage patients with 

*preparation for Laser assisted labial frenoplasty.*

*Figure 11: Showing the Laser setup in the dental office as well as surgical site*

The indication for crown lengthening is: cases of satisfying harmony of the upper lip height and maxillary bone relation, healthy dentition and periodontium but with poor dentogingival relation such as gingival overgrowth or poor architecture. It is used as well to optimize the restorability of the coronal portion of teeth. [14, 15] **The disadvantages**: Asymmetry, might require re‐treatment to remove

**The advantages**: done under office local anesthesia, can be done using a laser for less bleeding and better postoperative recovery. more gingival tissue or/ and bone, gingival recession, discomfort that lasts for few days. (14, 15)

**The disadvantages**: Asymmetry, might require re-treatment to remove more gingival tissue or/ and bone, gingival recession, discomfort that lasts for few days. [14, 15] CASE PRESENTATION

A young male patient referred complaining of unesthetic anterior maxillary

#### *4.4.1. Case presentation* teeth. On clinical and radiographic evaluation, the patient had a poor

(**Figure 13**). (18)

A young male patient referred complaining of unesthetic anterior maxillary teeth. On clinical and radiographic evaluation, the patient had a poor dentogingival relation of the anterior maxillary teeth, poor crown shape, color and texture. The patient was presented to the team which advised a multi-step intervention starting from proper planning to restore the eight anterior teeth after a crown lengthening procedure using laser therapy (Figure 12). dentogingival relation of the anterior maxillary teeth, poor crown shape, color and texture. The patient was presented to the team which advised a multi‐step intervention starting from proper planning to restore the eight anterior teeth after a crown lengthening procedure using laser therapy (**Figure 12**).

**Figure 12: The picture on the left showing poor dentogingival relation of the anterior maxillary teeth. The right figure is showing the poor Figure 12.** The picture on the left showing poor dentogingival relation of the anterior maxillary teeth. The right figure is showing the poor alveolar crestal bone relation to the first maxillary right crowned incisor, which looks short and misshapen. Those poor relations lead to esthetically non-balanced anterior maxillary teeth.

#### **alveolar crestal bone relation to the first maxillary right crowned incisor, which looks short and misshapen. Those poor relations lead to 4.5. Internal smile procedures (patient's personal satisfaction)**

**esthetically non‐balanced anterior maxillary teeth.** ‐ **INTERNAL SMILE PROCEDURES (patient's personal satisfaction)** Some patients can be unsatisfied with their smiles regardless of the type of treatment planned. Unless the operator figures out the exact factor contributing to the problem treatment will not really work. To provide Some patients can be unsatisfied with their smiles regardless of the type of treatment planned. Unless the operator figures out the exact factor contributing to the problem treatment will not really work. To provide examples, patients might be looking for cheek, lip, or chin piercing as the major key factors to their internal satisfaction while others, regardless of the procedures performed on their teeth, a single cheek dimple may be the change that the patient desires. And once that left cheek dimple procedure is performed, self-satisfaction is reflected positively on the actual smile (Figure 13). [18]

examples, patients might be looking for cheek, lip, or chin piercing as the major key factors to their internal satisfaction while others, regardless of the procedures performed on their teeth, a single cheek dimple may be the change that the patient desires. And once that left cheek dimple procedure is performed, self‐satisfaction is reflected positively on the actual smile

Some patient can be unsatisfied with their smiles regardless of the type of treatment planned. Unless the operator figures out the exact factor contributing to the trouble, 

To provide examples, patients might be looking for cheek, lip, or chin piercing as the 

major keyfactor to their internal satisfaction while others, (case in figure 13) regardless of the procedures performed on her teeth, the patient reported that a 

single cheek dimple on her left cheek was the change that she was hoping to implement. And once that left cheek dimple procedure was performed, her self‐

satisfaction reflected positively on her actual smile (Figure 13). (18) 

**Figure 13: The patient had the desire to get a dimple on the left cheek that made her satisfied with her smile. The postoperative Figure 13.** The patient had the desire to get a dimple on the left cheek that made her satisfied with her smile. The post‐ operative picture on the right side indicates a more pleasant smile. Other situation, where patients can be presented with acceptable jaw skeletal 

**picture on the right side indicates a more pleasant smile.** Another situation, is where patients can have acceptable jaw skeletal Another situation, is where patients can have acceptable jaw skeletal relations, however, microgenia (small chin bone) or macrogenia (large chin bone) reduces their self-satisfaction of their smiles (Figure 14). Such chin deformities can be treated with genioplasty, chin augmen‐ tation or chin reduction procedures [2, 5, 7, 9, and 13]. relation, however, with microgenia (small chin bone) that reduces their self‐ satisfaction to their smiles (Figure 14), or macrogenia (large chin bone). Such chin deformities can be treated with genioplasty; chin augmentation or chin reduction procedures (2,5,7,9,13). 

**Figure 14.** Although the patient presented with what looks like a retruded lower jaw (left), his occlusion is in an ac‐ ceptable relation, that clarifies that the defect is mainly at the chin level, microgenia (right).
