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Assessment of the Efficiency of Botox and Lip Reposition in the Correction of the Gummy Smile According To the Patients' Satisfaction

Volume 1 | Issue 1 | 1 of 4
Oral Health Dental Sci, 2017
Assessment of the Efciency of Botox and Lip Reposition in the Correction
of the Gummy Smile According To the Patients' Satisfaction
MSc, Department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Tishreen University, Lattakia, Syria.
Mohammad Osama Makkiah, Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Tishreen University, Lattakia, Syria,
Tel: 00693966160022, E-mail:
Received: 02 November 2017; Accepted: 05 December 2017
Dr. Mohammad Osama Makkiah*
Oral Health & Dental Science
This study aims to evaluate the eectiveness of both injection botulinum toxin type A (botox) and surgical
lip reposition in the correction of the gummy smile due to hyperactive upper lip according to the resulting
smile and the patients' satisfaction. This is done to determine the less damaging to the tissues and more
stable alternative in giving results with statistical importance and aesthetically satisfying results. The
method consists of 24 patients: 12 received the BTX-A injection and the remaining 12 underwent the surgical
procedure (lip reposition). The patients rated their satisfaction according to their gingival display that was
dened as the dierence between the lower margin of the upper lip and the superior margin of the right
incisor, and patients were followed at 2 weeks, 2 months and 6 months. Post injection and post surgery
with changes documented by photographs. Both groups answered a questionnaire addressing the overall
appearance and they were asked to rate the improvement of their smile according to a 5-point aesthetic scale
BTX-A injection exhibits better results than those of surgery and had given safer and more satisfactory results
than lip reposition. The patients rated the eects of BTX-A as highly favorable if we take into consideration
that BTX-A was temporary eect but the surgical procedure (lip reposition) is 80% recurrent surgery because
the lip reverted back to its original position with almost complete relapse after 6 months later and containing
all the dangers aliated with the surgical procedures.
Research Article
Citation: Mohammad Osama Makkiah. Assessment of the Eciency of Botox and Lip Reposition in the Correction of the Gummy
Smile According To the Patients' Satisfaction. Oral Health Dental Sci. 2017; 1(1); 1-4.
Botox, Lip reposition, Gummy smile, Hyperactive upper lip the
patient satisfaction, Botulinum toxin type A, BTX-A.
Gummy smile or “high smile line” or “gingival smile line” is
a condition characterized by excessive exposure of maxillary
gingiva during smiling, where the upper lip moves up about 6-8
mm during the smile so that it appears more than 2 mm from the
gingiva and all the clinical crown length of the patients' teeth. This
results in signicant consequences where the patient would rather
hide his/her smile in order to avoid embarrassment [1-3]. 7% of
young adult males and 14% of young adult females have gummy
smile [4].
The muscles of facial expression which are responsible for upper
lip elevation and lateral retraction upon smiling are levator labii
superioris alaeque nasi (LLSAN), levator labii superioris (LLS),
zygomaticus minor ( Zm), zygomaticus major (ZM), risorius, and,
to a lesser degree, the depressor septi nasi muscle. All of these
muscles interact with the orbicularis oris muscle in the production
of a smile [5].
The various causes of gummy smile include vertical maxillary
excess, anterior dentoalveolar extrusion, delayed passive dental
eruption, short or hyperactive upper lip elevator muscles [4,5].
Treatment of Gummy smile by aesthetic crown lengthening with or
without osseous resection is well documented [6,7]. Dentoalveolar
extrusion can be treated successfully by orthodontic therapy [8].
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Gummy smile due to vertical maxillary excess can be successfully
treated by orthognathic surgery [9].
However, this surgery is associated with signicant morbidity
and requires hospitalization. Therefore, lip repositioning is
recommended as an alternative treatment for gummy smile due to
hyperactive upper lip. The objective of lip repositioning is to limit
the retraction of elevator smile muscles. Lip repositioning results
in a shallow vestibuler restricting of the muscle pull; Thereby
limiting the gingival display during smiling.
The procedure was rst described in the literature of plastic
surgery in 1973 by Rubinstein AM. There is still scarcity of work
and literature regarding lip reposition surgeries with only cases
being published by Rosenblatt and Simon [1] and Gupta et al. [2].
A new technique for the treatment of GS is botulinum toxin
injection [13]. First reported in a pilot study by Polo in 2005,12
botulinum toxin injection for GS treatment showed promising
results, but the eect of the botulinum toxin was temporary.
Materials and Methods
Study exclusion criteria included known allergies to albumin or
any other ingredients in BTX-A, patients taking aminoglycoside
antibiotics or other agents interfering with neuromuscular
transmission, patients with peripheral motor neuropathies or
functional neuromuscular disorders, or patients who were pregnant
or breastfeeding.
After initial consultation and evaluation, 24 female patients were
enrolled in this study, 12 received the BTX-A injection and the
remaining 12 underwent the surgical procedure (lip reposition).
Measurements were taken from the gum line at the midline of the
central incisors and canines to the lowest portion of the upper lip.
To obtain maximal patient smile during measurement, funny jokes
were made.
Surgical procedure technique
Adequate local anesthetic (lignocaine 2% with epinephrine
1:100,000) was administered in vestibular mucosa and lip from
maxillary right rst molar to maxillary left rst molar. The surgical
site was marked with an indelible pencil. A partial thickness ap
was raised from mesial line angle of right maxillary rst molar to the
mesial line angle of left maxillary rst molar at the mucogingival
junction. A second incision 11-14 mm above the rst incision was
made in the labial mucosa. The two incisions were joined on either
side and a strip of partial thickness ap was removed, exposing the
underlying connective tissue [Figure 1].
The two incisions were then approximated using continuous
interlocking sutures [Figure 1]. Patient was prescribed nonsteroidal
anti-inammatory drugs (diclofenac sodium 50 mg three times
daily for 3 days) and oral antibiotics (Augmentin 1g two times
daily for 5 days). Patient was instructed to apply ice pack post
operatively and minimize lip movement for 10 days. Sutures were
removed 3 weeks post operatively.
Figure 1: The phases of lip reposition.
Comparison between the averages of satisfaction of the two types of
treatment in various periods.
Injections technique
Figure 2: The phases of BTX-A Injection.
Each patient underwent injections of BTX-A at 3 sites bilaterally
into the levator labii superioris and levator labii superioris alaeque
nasi muscles. The supercial facial landmarks used for injection
sites were as the following: 2 mm lateral to the alar-facial groove
at the level of the nasal passage, followed by an injection 2 mm
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lateral to the rst injection in the same horizontal line, with the last
injection 2 mm inferior and between the rst 2 sites. The resulting
injection sites were mapped in an inverted triangle. Furthermore,
the bony landmark was the anterior maxilla that correlates with the
overlying musculature described above.
BTX-A was diluted according to the manufacturer’s
recommendations to yield 2.5 units per 0.1 mL by adding 4.0 mL
normal saline solution to 100 units of vacuum-dried Clostridium
botulinum toxin type A. Under sterile conditions, 2.5 units were
then injected in all subjects at previous sites.
On the rst follow-up visits, each patient from both groups
answered a questionnaire addressing the following aspects:
The overall the appearance.
Rate the improvement of their smile according to a 5-point
aesthetic scale (5 = excellent, 4 = very good, 3 good, 2 = fair,
1 = poor).
Their willingness to repeat the treatment.
The level of satisfaction during the followed periods (after
two weeks, after two months, after six months).
Whether they would recommend this treatment to others with
a similar diagnosis.
Pretreatment and posttreatment questionnaire responses, in
addition to directly questioning the patients, enabled us to evaluate
the patients' satisfaction.
In order to study patients' satisfaction with the outcome, the results
were as the following table 1.
The Treatment Statistical index After Two
After Two
After Six
Lip reposition
mean 2.08 3.92 1.67
number 12 12 12
standard deviation .793 .900 .651
less value 1 2 1
greater value 3 5 3
mean 2.42 4.50 1.33
mumber 12 12 12
standard deviation .996 .522 .492
less value 1 4 1
greater value 4 5 2
Table 1: The patient satisfaction about the outcome results.
Patents with injection treatment, depending on the answers of the
questionnaire and the interview with the patient, they felt the smile
seemed more beautiful than before during the rst three days after
injection. When asked when they felt change, smiling responses
ranged from (1-7 days) and average (3.5 days).
Patents with surgery treatment, depending on the answers of the
questionnaire and the interview with the patient, they felt the smile
seemed more beautiful than before during the rst day after the
lip reposition procedure, but they reported mild pain and tension
while smiling during the rst week after surgery. . When asked
when they felt change, smiling responses ranged from (1-5 days)
and average (2.5 days).
Concerning the satisfaction with the Botox treatment, the values of
the patients and their awareness to improve the aesthetics of their
smile were with an average of 4.50 out of 5, a number of high level
of satisfaction. As for the desire to re-treatment again, responses
were (9 yes), (2 maybe) and (1 responded in the negative). When
they would were asked whether they advise others who have the
same situation to undergo this treatment, the answers were (11 yes)
and (1 No).
But In terms of satisfaction with the surgical treatment, the values
of the patients and their desire to improve the aesthetics of their
smile with an average of 2 out of 5, a number of poor level of
satisfaction due to the lip reverted back to its original position with
almost complete relapse after 6 months from surgical procedure.
As for the desire to re-treatment again responded (yes 1) and (1
maybe) and (10 responded in the negative). When they asked
whether they advise others who have the same situation to do this
treatment answered (yes, 1) and (11 no).
The patients complain about feeling that they cannot laugh or smile
during the rst two weeks and attribute this to the obstruction of
the lips that cannot be explained, but after two months, they were
enabling to adapt the new situation and learn how to smile.
No prolapse in the upper lip or protrusion of the lower lip was
mention. Also an asymmetry between the lips, drooling, dicult
speaking and eating after either surgery or injections were
A gummy smile is the excessive display of gingival tissue in the
maxilla upon smiling .It can be self-conscious, embarrassing or
even psychologically mortifying, and thus needs intervention
[11-13]. The proper diagnosis and determination of its etiology
are essential for the selection of the right treatment modality [5].
Dierent techniques have been used in cases of hyperactive upper
lip: botulinum toxin injections, lip elongations with rhinoplasties,
lip muscle detachments, myotomies, and lip repositions.
The lip repositioning technique is an excellent alternative to
more costly procedures with higher morbidity rates [1,2]. The
lip reposition surgery was originally described in the medical
literature by Rubenstein and Kostianovsky in 1973. Previously
Polo [10], reported the benets of BTX-A was reported in 5
patients with gummy smiles. The purpose of that pilot study was
to determine whether injecting BTX-A at particular muscle sites
could provide an alternative therapy for gummy smiles caused by
hypercontractibility or excessive muscle contraction. The eect
of the botulinum toxin was temporary, and the gingival display
Volume 1 | Issue 1 | 4 of 4Oral Health Dental Sci, 2017
© 2017 Makkiah MO. is article is distributed under the terms of the Creative Commons Attribution 4.0 International License
gradually increased from the second week to baseline values after
the 32nd week [14,15].
Our study found the eect of the botulinum toxin was temporary
and that the gingival display gradually increased after the 32 weeks,
but in lip reposition (the surgery procedure), the lip reverted back
to its original position with almost complete relapse after 6 months
of surgical procedure.
We noticed that the highest level of satisfaction was after two
months in the cases of the patients who were injected with toxin
toxin type A (Botox) but that satisfaction dropped after six months
and the same result was noticed in the cases of the patient who
were treated by surgery.
However, we note that in the three comparisons remains
satisfaction, the treatment by injecting toxin toxin type A (Botox)
is higher than treatment with surgery.
BTX-A injection exhibits better results than those of surgery and
had given safer and more satisfactory results than lip reposition.
The Patients rated the eects of BTX-A as highly favorable if we
take into consideration that the surgical procedure (lip reposition)
is 80% recurrent surgery containing all the dangers aliated with
the surgical procedures.
1. Rosenblatt A, Simon Z. Lip repositioning for reduction of
excessive gingival display a clinical report. Int J Periodontics
Restorative Dent. 2006; 26: 433-437.
2. Gupta KK, Srivastava A, Singhal R, et al. An innovative
cosmetic technique called lip repositioning. J Indian Soc
Periodontol. 2010; 14: 266-269.
3. Matthews TG. The anatomy of a smile. J Prosthet Dent. 1978;
39: 128- 134.
4. Garber DA, Salama MA. The aestheticsmile Diagnosis and
treatment. Periodontol 2000. 1996; 11: 18-28.
5. Silberberg N, Goldstein M, Smidt A. Excessive gingival
display– etiology, diagnosis, and treatment modalities.
Quintessence Int. 2009; 40: 809-818.
6. Lee EA. Aesthetic crown lengthening Classication, biologic
rationale, and treatment planning considerations. Pract Proced
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7. Chu SJ, Karabin S, Mistry S. Short tooth syndrome Diagnosis,
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9. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, et al. New
approach to the gummy smile. Plast Reconstr Surg. 1999;
104: 1143-1150.
10. Suber JS, Dinh TP, Prince MD, et al. OnabotulinumtoxinA
for the treatment of a gummy smile. Aesthet Surg J. 2014; 34:
11. Polo M. Botulinum toxin type A Botox for the neuromuscular
correction of excessive gingival display on smiling gummy
smile. Am J Orthod Dentofac Orthop. 2008; 133: 195-203.
12. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin a
new approach based on the gingival exposure area. J Am Acad
Dermatol. 2010; 63: 1042-1051.
13. Polo M. Botulinum toxin type A in the treatment of excessive
gingival display. Am J Orthod Dentofacial Orthop. 2005; 127:
14. Diamond O. Facial esthetics and orthodontics. J Esthet Dent.
15. de Maio, Mauricio, Rzany, Berthold. Botulinum Toxin in
Aesthetic Medicine. Dermatology. 2007.
... Osama Makkiah [16], their results suggested that modified lip repositioning did not represent the degree of patient satisfaction as botox injection due to pain and tension. ...
... All articles included showed a significant improvement in gingival exposure after BTX-A injection, being considered a safe treatment when used in appropriate dosages and settings (online resource 2). Patients reported feeling a difference when smiling on average 3-5 days after application [21], and the result considered extremely satisfactory occurred after 14 days [22,23]. Some patients reported mild side effects, such as functional difficulties [20], spasms at the application site, headache, and dizziness [6]. ...
Full-text available
Objective The aim of this systematic review is to synthesize the evidence on the effectiveness and longevity of the botulinum toxin in the treatment of individuals with excessive gingival exposure.Methods The search was adapted to six electronic databases and gray literature. The risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool for Non-Randomized and Randomized Studies of Interventions. Meta-analyses and meta-regression were performed using random effects models.ResultsA total of 5247 articles were collected during the final search in the database, resulting in 17 articles included. There was a mean decrease of 3.42 mm [95% CI = −4.50 to −2.34; I2 = 97%] in the level of gingival exposure 2 weeks after the application of botulinum toxin. The application time explained 29.58% of the observed variance (p < 0.001), with a tendency for the effect size to decrease from the second week of application onwards, with values returning close to baseline levels in 24 weeks.Conclusion Botulinum toxin is an alternative technique considered effective for reducing gummy smile, especially for gummy smiles up to 4 mm, with a longevity of at least 12 weeks, returning close to initial values within 24 weeks after application.Clinical relevanceThe knowledge about the longevity and effectiveness of botulinum toxin in the treatment of gummy smile allows for a more adequate clinical planning for these cases, as well as for clinical decisions, as for prognostic factors.
... The use of BT is particularly effective in managing cases of excessive gingival display due to excessive contraction of upper lip muscles, and primarily levator labii superioris alaeque nasi (4,15) . A study reported that BTX-A injection exhibits better results than those of surgery and had given safer and more satisfactory results than lip reposition (16) . ...
Full-text available
Abstract Objective: Gummy smile (GS) also referred to an excessive gingival display (EGD). it’s an aesthetic disorder that can be managed by a variety of procedures include; modified lip reposition surgery (MLRS) and botulinum toxin type-A injection (BTX-A). This study aimed to evaluate and compare the effect of treatment of GS by surgical technique (MLRS) and non-surgical technique (BTX-A injection) 1 and 4 months after treatment. Methods: The study was conducted from November 2018 to November 2019. Forty adult patients aged 18-35 years with a EGD ≥ 4 mm caused by soft tissue disorders were recruited. Patients divided into two groups; Group 1 included 20 patients treated by MLRS and Group 2 (20 patients) treated by BTX-A injection. The amount of gingival display (GD) was evaluated after 1 and 4 months of the treatments by Autodesk AutoCAD computer program. ANOVA test used to compare changes in GD before and following treatments. Results: The study showed a significant reduction in the amount of GD in both groups after 1 and 4 months of the treatment (p value < 0.05). Non-significant differences between both groups in 1 and 4 months of follow up (p value > 0.05). Conclusions: Both MLRS and BTX-A injection technique were effective treatment modalities for patients suffering from GS. Keywords: Gummy smile, Gingival display, Lip reposition surgery, Botox injection.
Full-text available
A clinical report describing the successful use of the lip repositioning technique for the reduction of excessive gingival display. A female patient aged 34 years reported with a chief complaint of gummy smile and was treated with this technique performed under local anesthesia with the main objective to reduce gummy smile by limiting the retraction of elevator muscles (e.g., zygomaticus minor, levator anguli, orbicularis oris, and levator labii superioris). The technique is fulfilled by removing a strip of mucosa from maxillary buccal vestibule and creating a partial thickness flap between mucogingival junction and upperlip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display.
Full-text available
Unlabelled: The rationale for crown lengthening procedures has progressively become more aesthetic-driven due to the increasing popularity of smile enhancement therapy. Although the biologic requirements are similar to the functionally oriented exposure of sound tooth structure, aesthetic expectations require an increased emphasis on the appropriate diagnosis of the hard and soft tissue relationships, as well as the definitive restorative parameters to be achieved. The development of a clinically relevant aesthetic blueprint and attendant surgical guide is of paramount importance for the achievement of successful outcomes. Learning objectives: This article provides a classification system that clinicians can use when treatment planning for aesthetic crown lengthening. Upon reading this article, the reader should have: A clear understanding of the involved biological structures. Didactic instruction on the classification and treatment planning for aesthetic crown lengthening procedures.
Background: Excessive gingival display, or a “gummy smile,” is defined as 2 mm or more of gingival exposure upon smiling. Such excessive gingival exposure can be aesthetically unappealing to patients. One factor that contributes to a gummy smile is hyperfunctional lip elevator muscles. Objectives: The authors evaluate onabotulinumtoxinA as a safe and minimally invasive treatment for a gummy smile. Methods: In this prospective study, 14 patients (13 women, 1 man) underwent pretreatment photographs and measurements, followed by bilateral injection of onabotulinumtoxinA into their lip elevator muscles. All patients selected for the study had more than 2mm of gingival show and were classified as having a “cuspid smile,” where action of all elevator muscles raised the upper lip— like a window shade—to expose the upper teeth and gingival scaffold; these patients were thought to have a better chance for a more superior result. Repeat measurements and photographs were collected at 2 weeks and 3 months. Patient-reported outcomes were collected at 2 weeks, and data were compared to determine the correlative relationship. Results: An average of 5 units (range, 4–6 U) of onabotulinumtoxinA were injected into 3 sites bilaterally. The average preinjection gingival show over the central incisors and canines were 4.89 mm and 4.25 mm, respectively. Postinjection gingival show decreased to an average of 0.75 mm (85% improvement) and 0.74 mm (83% improvement) over the central incisors and canines, respectively. Average follow-up time was 12.6 days. One patient felt the resulting smile was unattractive and opted not to undergo repeat injections, while all other study participants experienced no negative effects and wished to undergo repeat treatment. Conclusions: As treatment for a “gummy smile,” onabotulinumtoxinA provides an effective, minimally invasive, and safe therapy. This treatment option can lead to significant improvement in smile aesthetics with high patient satisfaction. Level of Evidence: 3
Gummy smile (GS) is an aesthetic disorder for some patients, which can be corrected by injection of botulinum toxin. We sought to classify GS according to the area of gingival exposure and the respective muscles involved in order to perfect the botulinum toxin injection technique for each patient. Sixteen patients with GS were evaluated before receiving botulinum toxin injections. Based on the area of excessive gum displayed and identification of the muscles involved, 4 different types of GS were identified: anterior, posterior, mixed, and asymmetric. AbobotulinumtoxinA (Dysport, Ipsen Biopharm Limited, Wrexham, UK) was injected using a different injection technique for each type of GS, based on the main muscles involved. With the aid of two computer programs, the area of gum exposed was measured before and after the application of abobotulinumtoxinA, to evaluate the level of improvement. There was a decrease in the degree of gum display in all patients. The general average improvement achieved was 75.09%. Two patients showed slight adverse effects that were easily corrected with additional doses of abobotulinumtoxinA. For this study, there was no sample size calculation and no statistical analysis of the cases. The authors conclude that it is important to identify the type of GS and therefore the main muscles involved, so that the correct injection technique can be used. AbobotulinumtoxinA was shown to be effective and safe for use in all types of GS in the present sample.
Extensive exposure of the gingiva during a smile, called excessive gingival display, may be a point of concern for both patients and clinicians. Patients often present to the dental clinic seeking a solution to their "gummy" appearance. A clinician must fully understand the various factors involved in this situation, to provide patients with an appropriate answer. Thorough examination followed by the right diagnosis is imperative for achieving an esthetic and predictable result in the treatment of such situations. The aim of this article is to discuss the various aspects of excessive gingival display and its etiology and to present the current solutions that exist in the literature.
The anatomy of the smile is an integral part of dentistry. Its understanding involves close scrutiny of all elements of the oral region. It is not enough to establish the size of teeth based on the high and low lip lines, size of the mouth, and a shade to blend with the age and complexion. To create a harmonious smile the dentist must maintain or create the normal curvature of the lips, proper exposure of the red zone of the lips, an undistorted philtrum, and undisturbed nasolabial grooves. These entities, maintained in harmony with the exposed teeth, constitute the anatomy of a smile. In order that patients may be served properly, the smile must be understood, recorded, and analyzed so that desirable aspects may be preserved and graceless components returned to attractiveness.
As we complete the 20th and progress into the 21st century, orthodontists worldwide are experiencing a gradual but significant change in their practices. The number of adult patients has increased substantially. Although adults cooperate better than adolescents, they present a different set of challenges for the orthodontist. Adults may have worn or abraded teeth, uneven gingival margins, missing papillae, and periodontal bone loss, all of which can jeopardize the esthetic appearance of the teeth after bracket removal. This article will discuss the solutions for managing these challenging orthodontic-periodontic-restorative situations to produce a more ideal esthetic result.
One cause of excessive gingival display is the muscular capacity to raise the upper lip higher than average. Several surgical procedures have been reported to improve the condition, but surgery always involves risk and is costly. Botulinum toxin type A (BTX-A) (Botox; Allergan, Irvine, Calif) has been studied since the late 1970s for the treatment of several conditions associated with excessive muscle contraction or pain. This clinical pilot study was performed to determine whether BTX-A injections would reduce excessive gingival display. Five subjects with excessive gingival display due to hyperfunctional upper lip elevator muscles were treated with BTX-A injections. This treatment modality was effective, producing esthetically acceptable smiles in these patients. The improvements lasted 3 to 6 months. Injection with BTX-A at preselected sites is a novel, cosmetically effective, minimally invasive alternative for the temporary improvement of gummy smiles caused by hyperfunctional upper lip elevator muscles.