Volume 1 | Issue 1 | 1 of 4
Oral Health Dental Sci, 2017
Assessment of the Efciency 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: Dr.Osama.Makkia@gmail.com.
Received: 02 November 2017; Accepted: 05 December 2017
Dr. Mohammad Osama Makkiah*
Oral Health & Dental Science
This study aims to evaluate the eectiveness 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
dened as the dierence 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 eects of BTX-A as highly favorable if we take into consideration
that BTX-A was temporary eect 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 aliated with the surgical procedures.
Citation: Mohammad Osama Makkiah. Assessment of the Eciency 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 signicant 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
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 .
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 .
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Gummy smile due to vertical maxillary excess can be successfully
treated by orthognathic surgery .
However, this surgery is associated with signicant 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  and Gupta et al. .
A new technique for the treatment of GS is botulinum toxin
injection . First reported in a pilot study by Polo in 2005,12
botulinum toxin injection for GS treatment showed promising
results, but the eect 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
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
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-inammatory 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.
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 supercial 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
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, dicult
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 .
Dierent 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 , reported the benets 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 eect
of the botulinum toxin was temporary, and the gingival display
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© 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 eect 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 eects 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 aliated 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 Classication, biologic
rationale, and treatment planning considerations. Pract Proced
Aesthet Dent. 2004; 16: 769-778.
7. Chu SJ, Karabin S, Mistry S. Short tooth syndrome Diagnosis,
etiology and treatment management. J Calif Dent Assoc.
2004; 32: 143-152.
8. Kokich VG. Esthetics The orthodontic periodontic restorative
connection. Semin Orthod. 1996; 2: 21-30.
9. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, et al. New
approach to the gummy smile. Plast Reconstr Surg. 1999;
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.