A successful management of sever gummy smile using gingivectomy and botulinum toxin injection: A case report

Mini-plates as an alternative to Anterior Maxillary Osteotomy: A Case Series - JCO- Print ISSN No: - Online ISSN No:- 2582-0478 Article DOI No:- 10.18231/j.jco.2019.016, Journal of Contemporary Orthodontics-J Contemp Orthod

Currently, the search for esthetic excellence has become the main objective in the facial treatment. The gummy smile is one of the complaints from the patients, since this situation may influence their self-esteem and social relationship. The development of new techniques, such as the application of botulinum toxin, may be a conservative therapeutic option in the treatment of gummy smile. The purpose of this letter is to comment some points about a case report publicated in Dermatology Online Journal, of a patient with dentogingival discrepancy and severe gummy smile, who was treated with application of botulinum toxin in order to optimize the harmony of the smile.

Currently, the search for aesthetic excellence has become the main objective in the dental treatment. The gummy smile is one of the complaints from the patients, since this situation may influence their self-esteem and social relationship. The development of new techniques, such as the application of botulinum toxin, may be a therapeutic option more conservative, in the treatment of gummy smile. The purpose of this article is to present a case of a patient with dentogingival discrepancy and severe gummy smile, who was treated with gingivoplasty and application of botulinum toxin in order to optimise the harmony of the smile.

Excessive Gingival Display (EGD), commonly known as a gummy smile, is a significant aesthetic concern. The factors responsible for EGD include altered passive eruption, a short or hyperactive upper lip, vertical maxillary excess, or a combination of these. The classic treatment for severe cases of vertical maxillary excess and EGD is orthognathic surgery. However, Aesthetic Crown Lengthening (ACL) and Lip Repositioning (LR) can offer a conservative, minimally invasive and reliable alternative for treating EGD. This case report focuses on managing EGD using a conservative, minimally invasive mucosal strip surgical technique for a 23- year-old female patient who presented with a severe gummy smile. Management was planned with a combination of ACL and LR. A CAD-CAM milled surgical guide was designed and printed by superimposing Stereolithography (STL) files of digital impressions, photographs and Digital Imaging and Communications in Medicine (DICOM) files from a Cone-beam Computed Tomography (CBCT) scan to provide a suitable and predictable reference for ACL. The LR was performed by resecting a mucosal strip and coronally repositioning the upper lip, thereby reducing the depth of the upper vestibule to restrict lip elevation during smiling, which in turn reduces the gingival display. A substantial reduction of 4 mm of gingival display was seen post-operatively. ACL and LR aided with CBCT can be considered a safe and conservative treatment option for EGD.

ABSTRACTAim:This study aimed to compare the effectiveness, duration, and patient satisfaction of botulinum toxin A (BTX-A) and hyaluronic fillers in treating gummy smiles.Materials and Method:A prospective clinical study was conducted at D.Y. Patil University, involving 14 patients aged 18–40 years with a gummy smile of ≥3 mm. Participants were divided into two groups: Group A (BTX-A injections) and Group B (hyaluronic fillers). Gingival display was measured using standardized photographic methods at baseline and follow-up visits (14, 30, 60, and 90 days). Patient satisfaction was evaluated using the Global Aesthetic Improvement Scale (GAIS).Result:The results indicated that while BTX-A provided immediate improvements, hyaluronic fillers demonstrated more consistent and prolonged results. Patient satisfaction was higher in the hyaluronic filler group, with most patients reporting exceptional improvement (GAIS score of 1) across all follow-ups. No severe adverse effects were observed in either group.Conclusion:Hyaluronic fillers demonstrate superior effectiveness and patient satisfaction compared to BTX-A in the treatment of gummy smiles.

To evaluate the effect and longevity of Botulinum toxin type A (Botox®) in the management of gummy smile – A longitudinal study upto 4 years follow-up

The gummy smile is characterized by a marked gingival exposure on smiling and it has been considered as one of the main complaints of patients, also influencing on self-esteem and social relationship. The development of new techniques such as botulinum toxin application may be a more conservative treatment option than surgical intervention (myectomy and Le Fort I osteotomy) in the treatment of gummy smile. Objective: To present the case of a patient who presented dental-gingival discrepancy and gummy smile, treated by gingival resection surgery and complemented by the application of botulinum toxin. Case report: A female patient, 23 years old, presented dental-gingival discrepancy and gummy smile, treated by gingival resection surgery and complemented by the application of botulinum toxin. Results: The gingival resection surgery promoted improvement of dental relationship, caused by increase of dental zenith and the application of botulinum toxin caused uniform dehiscence of the upper lip, increasing the harmony of the smile and improving self-esteem and quality life. Conclusion: Botulinum toxin is an additional option in the cosmetic improvement of the smile and gives better results when combined with gingival resection surgery.

Excessive gingival exposure (gummy smile) is a non-aesthetic condition characterized by excessive exposure of the gingiva during smiling. The most common cause of gummy smiles was reported to be the hyperfunction of the muscles of the upper lip. Previous reports showed that botulinum toxin (Botox) is effective in the treatment of gummy smiles with a reversible effect, rapid initial action, safe application, low risk, and satisfactory outcome. The effect of Botox is usually observed between one and two weeks. This study aims to review the recent updates and guidelines for gummy smile treatment using botulinum toxin. A literature review was conducted involving relevant studies discussing gummy smile treatment using botulinum toxin with no time restriction. The PubMed and Google Scholar databases were used to gather the most relevant studies. The initial screening revealed 62 studies, and after removing the out-of-scope studies, the final review included 28 studies. Botulinum toxin can be used effectively for the treatment of gummy smile caused by lip dynamics with rarely reported complications. However, the most observed limitation was the temporary duration, which was reported to range from four to six months, and the re-injection of botulinum toxin is usually needed.

Severe high angle Class II Division 1 malocclusion with vertical maxillary excess and gummy smile: A case report

Background: Excessive gingival display, or “gummy smile,” occurs in up to 14% of adults and is associated with lip hyperactivity, dentoalveolar extrusion, or vertical maxillary excess. Botulinum toxin A (BTA) has emerged as a minimally invasive therapeutic option, but protocols vary widely and long-term data are limited. Objectives: To critically evaluate the current literature on BTA in gummy smile management, focusing on classification systems, injection techniques, efficacy, safety, and comparative outcomes against conventional surgical and orthodontic treatments. Methods: A narrative review was performed using PubMed, MEDLINE, and Scopus (2000-2023) with the terms “gummy smile,” “excessive gingival display,” and “botulinum toxin.” Clinical studies, case series, and reviews addressing BTA use were included. Data were synthesized into thematic categories. Results: BTA consistently reduced gingival exposure by 3 to 5 mm, with effects lasting 4 to 6 months. Three main injection strategies were identified: single-point (Yonsei), multi-point, and orbicularis oris (“lip flip”). Reported complications were rare and transient (mild asymmetry, lip weakness). Standardized protocols were lacking, with heterogeneity in dosing (2-5 units per site) and injection depth. Comparative studies suggested BTA is less durable than surgical approaches but offers superior patient acceptability and safety for mild to moderate cases. Conclusion: BTA provides reproducible, temporary improvement in gummy smiles with high safety and satisfaction rates. However, absence of consensus on optimal technique and limited long-term evidence highlight the need for standardized protocols and prospective multicenter studies.

Background. The present study aimed to assess the effect of botulinum toxin type A (BTX-A) for the management of gummy smile and evaluate its stability after administrating BTX-A clinically and using electromyography. Methods. The investigators designed and implemented a prospective clinical study on 10 patients with a gummy smile. Patients with different types of gummy smile were injected with BTX-A in the levator muscles of the upper lip and were followed for six months. The effect of BTX-A was evaluated clinically and using electromyography preoperatively and after two weeks and three and six months. Statistical analyses were carried out using repeated measures ANOVA and post hoc Bonferroni tests for pairwise comparisons. Results. The sample consisted of 10 patients with an anterior gummy smile (n=3), posterior gummy smile (n=2), mixed gummy smile (n=3), and asymmetrical gummy smile (n=2). There were significant differences (P < 0.001) between the mean gingival display and compound muscle action potential at two-weeks and three-month follow-ups. The maximum result was obtained at the two-week interval. The mean gingival display and C-MAP values increased slightly at the three-month postoperative interval and gradually increased to the baseline values at six-month follow-up. Conclusion. BTX-A is an effective, minimally invasive, and temporary treatment modality for gummy smiles. The electromyographic study is a convenient method for assessing changes in the upper lip muscle contractility to quantify the effect of BTX-A in the treatment of gummy smile.

Currently, concern about facial attractiveness is increasing, and this fact has led to orthodontics in adult patients being an increasingly demanded treatment, and with it, multi-disciplinary work. When it is caused by a vertical excess of the maxilla, the ideal solution is orthognathic surgery. However, in borderline cases and when the cause is hyperactivity of the upper lip levator muscle complex, alternative conservative solutions can be considered, such as the application of botulinum toxin A (BTX-A). Botulinum toxin is a protein produced by a bacterium and causes a reduction in the force of muscle contraction. The multi-factorial nature of the smile requires an individualized diagnosis in each patient, since there are multiple ways to treat the gummy smile (orthognathic surgery, gingivoplasty, orthodontic intrusion). In recent years, interest has grown in the simplest techniques that allow the patient to quickly return to their usual routine, such as lip replacement. However, this procedure shows recurrences in the first 6–8 post-operative weeks. The main objective of this systematic review and meta-analysis is to analyze the effectiveness of BTX-A in the treatment of gummy smile in the short term, to study its stability, and to evaluate potential complications. A thorough search of the PubMed, Scopus, Embase, Web of Science, and Cochrane databases and a grey literature search were conducted. The inclusion criteria were studies with a sample size greater than or equal to 10 patients with gingival exposure greater than 2 mm in smile, treated with BTX-A infiltration. Those patients whose exclusive etiology of their gummy smile was related to altered passive eruption, gingival thickening, or overeruption of upper incisors were excluded. In the qualitative analysis, the mean pre-treatment gingival exposure ranged between 3.5 and 7.2 mm, reaching a reduction of up to 6 mm after infiltration with botulinum toxin at 12 weeks. Although multiple muscles are involved in the facial expression, the muscles par excellence selected for blockade with BTX-A were levator labii superioris, levator labii superioris ala nasalis, and zygomaticus minor, infiltrating from 1.25 to 7.5 units per side. In the quantitative analysis, the difference in mean reduction between both groups was −2.51 mm at two weeks and −2.24 mm at three months. The benefit of BTX-A in terms of improvement of gummy smile is demonstrated, as a significant reduction in gummy smile is estimated by BTX-A therapy two weeks after its application. Its results gradually decrease over time, however, they stay satisfactory without returning to their initial values after 12 weeks.

Regarding “Efficacy of botulinum toxin for treating a gummy smile”

The aim was to evaluate the effect of botulinum toxin (Botox) injections as a conservative treatment for gummy smile. An experimental in vivo study was conducted at a dermatology clinic in Riyadh in January 2016. The study included 23 female patients who ranged from 20 to 50 years and were treated with Botox injections due to excessive maxillary gingival display. The patients with short clinical crowns or long maxilla, those who were pregnant or breastfeeding, and patients with neuromuscular disorders were excluded. Patients received Botox type I, injected 3 mm lateral to the alar-fascial groove at the level of the nostril opening at the insertion of the levator labii superioris alaeque nasi muscle. Photos were taken of the patient's smile before and after the treatment and were then uploaded to the SketchUp program to calculate improvements in gingival display. The distance from the lower margin of the upper lip to the gingival margin was calculated pre- and posttreatment. The amount of improvement was calculated as (pre-Botox treatment - post-Botox treatment/pre-Botox treatment × 100). The mean percentage of the total improvement was analyzed. A total of 23 female patients received treatment to improve their gummy smile. Improvement was clear 2 weeks after Botox injection. The mean percentage of improvement in the gingival display was 99.6%. Botox type I is an effective conservative technique to improve gummy smile caused by muscular hyperfunction. Patients' retention highly indicated that they were satisfied with the provided treatment by Botox injections. Improving the quality of life with least painful experience and immediate results was the major advantage for Botox type I.

Objective To investigate the incidence and characteristics of gummy smile in Han adolescents. Methods A self-imposed questionnaire of gummy smile was used. Gummy condition of 1156 Han people in Chongqing Medical University were measured when they smiled and displayed 8 maxillary anterior teeth. Smiles were divided into four categories (no gummy smile under 2 mm, gummy smile: mild 2-3 mm, moderate 3-4 mm, severe >4 mm). To investigate incidence of gummy smile, the differences between women and man groups and urban and rural groups were compared. Five examiners evaluated esthetics of mild, moderate and severe gummy smile. Results Incidence of gummy smile in Han adolescents was 17.91% (207). Incidence of mild, moderate and severe gummy smile were 10.03% (116), 6.22% (72) and 1.64% (19), respectively. Incidence of gummy smile in women 19.41% (172) was higher than men 12.96% (35) (P<0.05). There was no statistical difference between urban and rural groups. Conclusions Incidence of gummy smile is high in Han adolescents with a greater prevelance in females as compared to males. Severe gummy smile affects the esthetics severely and needs for treatment in order to improve self-image. Key words: Gummy smile; Han adolescents; Incidence