case_images: PMC11392582_01
case_images: Frontal views of the patient. (A) Vertical excess of the maxilla with the upper lip at rest without natural veiling. (B) Smile with an EGD of 8 mm on average.
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case_images: fig1
case_images: A 25-year-old female patient presented to the Brazilian Dental Association of Santa Catarina with the chief complaint of EGD (Figure 1(A)). The height of gingival display during a spontaneous smile averaged 8 mm (Figure 1(B)).
case_images: Intraoral view. (A) Markings for mucosal removal. (B) Removal of the band and exposure of the connective tissue on the left side.
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case_images: fig2
case_images: The incision outline was initially marked with a sterile pencil (Figure 2(A)). A partial thickness dissection was performed at the mucogingival junction, and all the epithelium was excised along the rectangular outline, exposing the underlying connective tissue (Figure 2(B)).
case_images: Intraoral view. Simple sutures with 5-0 Vicryl (Ethicon) providing closure of the upper and lower edges by first intention.
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case_images: fig3
case_images: In both areas, 5-0 Vicryl absorbable sutures (Ethicon) were used (Figure 3).
case_images: 30-day postoperative period of Modified LipStat. (A) Visible scar coinciding with the mucogingival line. (B) EGD of 4.5 mm on average.
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case_images: fig4
case_images: At 30 days postoperatively, there was a visible scar line (Figure 4(A)), consistent with other reports in the literature. The gingival display decreased to an average of 4.5 mm (Figure 4(B)).
case_images: Gypsum model of diagnostic waxing. The new shape and height of the teeth is defined by waxing.
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case_images: fig5
case_images: Based on these measurements, a diagnostic wax-up was created (Figure 5), and a mock-up was made (Figure 6) for the patient's approval.
case_images: Temporary crowns installed for visual assessment of new tooth dimensions and adjustment of disocclusion guides. Intraoral and profile view of the mock-up for the patient to adapt and approve the treatment.
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case_images: fig6
case_images: Based on these measurements, a diagnostic wax-up was created (Figure 5), and a mock-up was made (Figure 6) for the patient's approval.
case_images: ECL. (A) Initial incision using the surgical guide as a reference to remove excess keratinized gingiva. (B) Osteoplasty 3 mm above the margin of the surgical guide, demarcated with a micro Ochsenbein chisel.
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case_images: fig7
case_images: With the surgical guide in position, the excess keratinized gingiva was removed using a No. 15C scalpel blade (Swann-Morton) (Figure 7(A)). To delineate this margin, a micro Ochsenbein chisel (Quinelato) was used (Figure 7(B)).
case_images: Osteoplasty 3 mm above the cementoenamel junction.
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case_images: fig8
case_images: Osteoplasty was refined with a high-speed spherical diamond bur (Komet) according to the cementoenamel junction of all the teeth involved (Figure 8).
case_images: De-epithelialization of the papillae with curved microscissors (Schwertz) to remove the epithelium on the papillae for future coverage with the flap.
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case_images: fig9
case_images: Intraoral view. Final stage of ACL surgery with flap repositioned using 5-0 Nylon sutures (Ethicon).
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case_images: fig10
case_images: The flap was closed with suspensory sutures over the papillae using 5-0 Nylon sutures (Ethicon), involving the palatal surface of the dental elements (Figure 10).
case_images: Front view. (A) Postoperative period of 4 months of Modified LipStat and 1 month of ECL. (B) Postoperative period of 6 months of Modified LipStat and 3 months of ECL.
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case_images: fig11
case_images: At the 30-day evaluation, proper healing of the gingival tissues was confirmed, and there was no need for esthetic restorations (Figure 11(A)). After 6 months of follow-up, the reduced gingival display was maintained (Figure 11(B)).
case_images: CBCT of the midface. (A) Alveolar bone remodeling on the buccal aspect. (B) New positions of the bone and gingival tissues in relation to the cementoenamel junction.
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case_images: fig12
case_images: Remodeled alveolar areas in the maxillary region are noted (Figure 12(A)). It is possible to confirm the new position of the bone crest in relation to the cementoenamel junction (Figure 12(B)).
case_images: Front view. (A) Initial appearance of the spontaneous smile. (B) Appearance of the spontaneous smile after 6 years of follow-up.
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case_images: fig13
case_images:  Figure 13(A) illustrates the patient's initial condition during spontaneous smiling. Figure 13(B) shows the spontaneous smile 6 years postoperatively.