# Modified Lip Repositioning Surgery in the Treatment of
## 2 Case Presentation  
A 47-year-old male patient, despite being a smoker, presented with good systemic and periodontal health. He attended the Egas Moniz School of Health and Science with the main complaint of excessive gingival display (EGD) (Figure 1A). The patient, classified as Angle Class I, had a brachyfacial appearance (Figure 1B), and exhibited clinical crowns without altered passive eruption, along with some incisal wear. Figure 1: _Cont._  
Figure 1: Cont. A length of 9.5 mm was observed in the central incisors due to incision edge wear, along with EGD being observed during the smile, extending from the right upper second premolar to the left upper second premolar. The height from the nasal base to the lower edge of the upper lip was 24 mm, which is considered a normal lip height for a male. The patient demonstrated hypermobility of the upper lip elevator muscles during smiling. In a situation considered normal, the upper lip rises 6 to 8 mm from the resting position to the spontaneous smiling position; however, in this case, the upper lip position rose on average 1.5 times more than what is considered normal. The height of exposed gingiva in the central incisor region during spontaneous smiling was approximately 5 mm (Figure 1C). According to the patient's report, there was a genetic predisposition as his father had the same lip condition. Cephalometric radiograph was obtained to exclude excess vertical growth of the maxilla, which may also lead to excessive gingival display (Figure 1D). A proposed lip repositioning surgery was performed after extra and intra-oral dissection using chlorheximide. The procedure was carried out under local anesthesia of the infraorbital nerve, supplemented with anesthesia in the vestibular sulcus and the keratinized gingival region, bilaterally, using 2% Articaine with 1:100,000 epinephrine. To delineate the areas for incision, a bilateral lip retractor (Espandex) was used to ensure consistent lip expansion on both sides (right and left). The initial contour of the incisions was marked with a sterilized dermatatological pencil (Surgical Marker) (Figure 2A). The lower border of the incision was delimited approximately 1 mm above the mucogingival line, and the upper border was delimited 10 mm above the previous one (twice the average gingival exposure height). The two lines were connected at the distal ends (in the regions of the first premolars), and the labial frenulum was preserved in the midline to maintain a reference during closure of the surgical edges. Figure 1: (**A**) Initial appearance of the smile. (**B**) Side view photograph (brachyfacial appearance). (**C**) Smile with an average 5 mm of EGD. (**D**) Cephalometry where normal size and position of the upper jaw were observed. Figure 2: _Cont._  
For the superficial mucosal incisions, the same bilateral lip retractor (Espandex) was employed to maintain adequate exposure. N\({}^{\circ}\) 15C scalpel blades were used. A partial-thickness dissection was performed, and all epithelium was excised along the rectangular contour, exposing the underlying connective tissue (Figure 2B-D). After removal of the mucosal strip on both sides, the first stage of deep suturing was initiated using slow-absorbing Polidiconanone (PDS) 5/0 suture (Atramat\({}^{\circledown}\) Internacional Farmaceutica S.A. de C.V., Cuautitlan Izcalli, Mexico). Modified horizontal mattress sutures were performed to limit movement of the muscles and tissues in the region, as well as to approximate the surgical edges before external sutures (Figure 3A,B). Figure 3: _Cont._  
Figure 2: (**A**) Markings. (**B**) Removal of the mucosal band. (**C**) Strips of mucosa removed. (**D**) Exposure of the connective tissue. The second stage of suturing was performed using the same absorbable thread. The technique used was interrupted simple sutures, ensuring complete coaptation of the surgical edges to guarantee proper alignment of the midline of the lip with the midline of the teeth (Figure 4).