Botulinum Toxin (Type A) as a Minimally Invasive Treatment for Gengival Smile: Case Report

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Introduction: A gummy smile (GS) affects the esthetic and the psychological status as it usually decreases the self-confidence leading to hidden or controlling the smile. A smile with more than 2 mm exposed gingiva is called gummy smile. It may be due to one or more of the following etiologies; altered passive eruption of teeth, dentoalveolar extrusion, vertical maxillary excess, and short or hyperactive lip muscles. The treatment of gummy smile should be planned according to its cause/causes. The purpose of this case report was to highlight the ability of combined treatment of gingivectomy and Botox injection technique in managing a severe gummy smile. Also, techniques, advantages, disadvantages, indication and contraindications of Botulinum toxin (BT) are discussed at the literacy. Presentation of the case: A 24 year old female patient with a severe gummy smile was refereed to the periodontal clinics of our institution. Clinical examination revealed that she has a GS of an 11-12 mm gingival exposed area that was indicated for orthognathic surgery. The GS was treated by a gingivectomy surgery to increase the clinical crowns of upper anterior teeth and the use of Botox injections. The treatment showed remarkable and satisfactory results instead of doing extensive surgery. Discussion and conclusion: It is important to assess the patients' esthetic expectations and show the possible therapeutic solutions that fit him. We revealed that BT is considered as one of the minimally invasive, quick and affordable modalities that can replace extensive surgical procedures for corrections of sever GS.
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The authors studied and provided treatment to patients with the complaint of gummy smile. Between October of 2009 and January of 2011, 52 unaesthetic smiles were evaluated and treated with onabotulinum toxin A. Botulinum toxin injection was an effective treatment, with an average satisfaction level of 9.75 on a 10-point scale. The levator labii superioris alaeque nasi is the ideal muscle for injection, and lopsided smiles could be resolved also with onabotulinum toxin A asymmetric injection. Gummy smile treatment with onabotulinum toxin A into the levator labii superioris alaeque nasi muscle is an effective method, with minimum risk of complications and very high patient satisfaction.
Abstract The objective of this article is to present 3 various types of gummy smile treated with botulinum toxin-A injection per site at Yonsei points. The patients, who visited the department to demand a more aesthetic smile, were classified according to gummy smile type: asymmetric, anterior, and mixed. Botulinum toxin-A injection at Yonsei point was considered. Preinjection and postinjection pictures were taken, and the severity of excessive gingival display was measured for each tooth between second premolars. Two weeks after botulinum toxin injections, no complication was noted. The amount of excessive gingival display for each tooth between second premolars was measured less than 3 mm, and the percentage of improvement for each case was calculated 100%. The botulinum toxin injection at Yonsei point may be a predictable and noninvasive treatment option for various types of gummy smile.
Patients with a severe gummy smile and a skeletal Class II profile are difficult to treat. This case report describes an effective treatment alternative for improving a gummy smile in a patient with a severe Class II molar relationship , severe crowding, and lip protrusion using zygomatic anchorage devices and improved superelastic nickel-titanium wires. A 36-year-old woman had an excessive overjet and a deep overbite with a bilateral Angle Class II molar relationship. The cephalometric analysis demonstrated a Class II skeletal relationship (ANB, 9.5), retro-clination of the mandible (FMA, 38.4), and severe labial inclination of the mandibular incisors (IMPA, 101.9). The main treatment objectives included normalizing the overjet and overbite, improving the gummy smile, and establishing a satisfactory occlusion. During treatment with fixed appliances, intrusion of the total maxillary dentition using skeletal anchorage and elimination of the bimaxillary protrusion were achieved. Improvement of the lateral profile and gummy smile enhanced facial esthetics. Intrusion and distalization of the maxillary denti-tion with skeletal anchorage and improved superelastic nickel-titanium wires provided a satisfactory dental occlusion, esthetic improvement, and adequate function. This approach should be considered as an alternative treatment option to orthognathic surgery for adults with high-angle skeletal Class II malocclusion and a gummy smile. (Am J Orthod Dentofacial Orthop 2017;152:693-705)
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.
Over the past decade, facial cosmetic procedures have become more commonplace in dentistry and oral and maxillofacial surgery. An increasing number of patients seek minimal invasive procedures. One of the most requested procedures is treatment with botulinum toxin type A (BoNTA). Treatment of dynamic rhytids and lines with BoNTA is effective and produces high rates of improvement with rapid onset and long duration of action (longer than 4 months for some patients) compared with placebo. This paper considers the history and pharmacology of this neurotoxin, and focusses on the literature concerning the treatment of different facial areas with BoNTA. It also presents clinical guidelines on the treatment of glabellar lines, the frontalis muscle, peri-orbital lines, gummy smile and masseter muscle hypertrophy. Knowledge about the mechanisms of action and the ability to use BoNTA as an adjunctive treatment are mandatory for those working in the field of cosmetic facial surgery.
To propose a safe and reproducible injection point for botulinum toxin-A (BTX-A) as a supplementary method for the treatment of gummy smile, as determined by assessment of the morphologic characteristics of three lip elevator muscles. A total of 50 hemi-faces from 25 adult cadavers (male 13, female 12; ages, 47 to 88 years) were used in this study. Topographic relations and the directions of the lip elevator muscles (ie, levator labii superioris [LLS], levator labii superioris alaeque nasi [LLSAN], and zygomaticus minor [ZMi]), were investigated. Possible injection points were examined through the study of predetermined surface landmarks. The insertion of the LLS was covered partially or entirely by the LLSAN and the ZMi, and the three muscles converged on the area lateral to the ala. The mean angle between the facial midline and each muscle vector was 25.8 +/- 4.8 degrees for the LLS, 55.7 +/- 6.4 degrees for the ZMi, and -20.2 +/- 3.2 degrees for the LLSAN; no significant differences were noted between male and female subjects or between left and right sides. The three vectors passed near a triangular region formed by three surface landmarks. The center of this triangle, named the "Yonsei point", was suggested as an appropriate injection point for BTX-A. The clinical effectiveness of the injection point was demonstrated in selected cases with or without orthodontic treatment. Under careful case selection, BTX-A may be an effective treatment alternative for patients with excessive gingival display caused by hyperactive lip elevator muscles.
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.
Previously, botulinum toxin type A (BTX-A) (Botox; Allergan, Irvine, Calif) was shown to be effective in reducing excessive gingival display in 5 patients with gummy smiles. This study was conducted to determine whether the doses and the primary injection sites used in the pilot study for the correction of gummy smiles provide consistent, statistically significant, and esthetically pleasing results. Thirty patients received BTX-A injections to reduce excessive gingival display. Gingival display was defined as the difference between the lower margin of the upper lip and the superior margin of the right incisor. Patients were followed at 2, 4, 8, 12, 16, 20, and 24 weeks postinjection, with changes documented by photographs and videos. At week 2, the patients rated the effects of BTX-A. A group of specialty clinicians also evaluated the effects of BTX-A. Preinjection gingival display averaged 5.2 +/- 1.4 mm in the 30 patients. At 2 weeks postinjection, mean gingival display had declined to 0.09 mm (+/- 1.06 mm) in 30 patients (t = 26.01, P <.00001). The average lip-drop at 2 weeks was 5.1 mm for 30 patients. Gingival display gradually increased from 2 weeks postinjection through 24 weeks, but, at 24 weeks, average gingival display had not returned to baseline values. Based on predictions from a third-order polynomial equation, the baseline average of 5.2 mm would not be reached until 30 to 32 weeks postinjection. Patients and specialty evaluators rated the effects of BTX-A as highly favorable. BTX-A injections for the neuromuscular correction of gummy smiles caused by hyperfunctional upper lip elevator muscles was effective and statistically superior to baseline smiles, although the effect is transitory.
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