Application of Botulinum Toxin at the Yonsei Point for the Treatment of Gummy Smile: A Randomized Controlled Trial.

Botulinum toxin for gummy smile correction

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

Introduction: The use of botulinum toxin type A (BTX-A) to correct gummy smile has become popular in recent years. Objective: To evaluate the effects of BTX-A application in the correction of gummy smile 2 and 32 weeks after application. Methods: The sample comprised 35 patients (30 female, 5 male) at a mean age of 25.51 years (±5.59) with gummy smile due to muscular hyperfunction. In each patient, 2U of botulinum toxin was applied in the levator labii superioris alaeque nasi, 2 mm from the nasolabial fold. Photographs of spontaneous smiles were taken at 3 stages: before, 2 and 32 weeks after BTX application. Measurements of the gingival display were performed with the Radioface Studio 2 Software, and the calibration used the actual size of the right maxillary central incisor. Comparison of the three stages evaluated was performed with repeated measures ANOVA and Tukey tests. Results: Gingival display decreased significantly 2 weeks after BTX-A application and increased after 32 weeks but did not return to the initial value. Conclusion: There was a significant improvement in gummy smile 2 weeks after botulinum toxin application, and a significant relapse in the gingival display after 32 weeks, however not returning to baseline values.

Botulinum toxin is a neurotoxin that has been utilized to induce chemo-denervation of muscles. Cutaneous wounds represent a special situation in which the tensile forces applied by these muscles on wound edges might have deleterious effects on the healing process. The aim of this review was to investigate such an effect and to review other mechanisms this toxin might have on the healing process. We also reviewed the role of botulinum toxin in the management of hypertrophic scars and cleft lip repair.

Dose and injection site of botulinum toxin type A for gummy smile management: A systematic review and bibliometric analysis

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.

The harmony of the smile depends not only on the dentition, but also on the gum tissue, which excessively exposed can negatively affect aesthetics of the smile. Exposure of a small amount of gum during a smile is acceptable however a smile in which the exposure of the gum is more than 2 mm is considered an aesthetic defect called gummy smile. Among the causes of gingival smile listed are: shortened or hyperactive upper lip muscles (levator labii superioris, levator labii superioris alaeque nasi, zygomatic minor muscles), vertical maxillary excess, extrusion of alveolar ridges, altered passive eruption. In the case of hyperactive upper lip muscles, botulinum toxin can be used — this procedure was used in the described cases, and the effects were assessed using the FotoMedicus system and measurements of gingival exposure. In first case Bocouture botulinum toxin was administered on both sides, 4 units bilaterally in the levator labii superioris muscle and 2 units into levator anguli oris muscle. In total, 12 units were given. During the follow‑up the patient reported the start of the effect from the 5th day after the supply with the maximum effect after 12 days. A 6 mm correction of gummy smile was achieved. In the second case 4 units of botulinum toxin were applicated bilaterally into levator labii superioris alaeque nasi muscle. A 3 mm correction of gummy smile was achieved. The aesthetics of the face in a smile definitely improved in both men.

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.

Efficacy of botulinum toxin for treating a gummy smile

Objective: This study aimed to compare the changes in the gummy smile in cases treated with botulinum toxin (BTX) application or orthognathic surgery. Methods: The retrospective sample comprised 61 subjects with gummy smile divided into 2 groups according to treatment received for gummy smile correction: 1-38 patients (6 male; 32 female), at a mean age of 28.60 years (s.d.=6.09), treated with BTX application; 2- 23 patients (7 males and 16 females) at a mean age of 29.59 years (s.d.=5.72) treated with orthognathic surgery. Patients from the BTX group refused to undergo orthognathic surgery. The measurement of the gingival exposure was performed in extraoral photographs of the posed smile, before and after treatment, and it was defined as the difference between the stomion of the upper lip and the incisal edge of the maxillary central incisor minus the height of maxillary central incisor obtained in the patient's dental casts. The data were obtained before (T1) and after treatment (T2) and change of gingival exposure with treatment (T2-T1). Intergroup comparison of gummy smile was performed with independent t-tests. Results: The surgical group presented significantly greater correction of the gummy smile with treatment than the BTX group. Conclusion: Gummy smile presented a greater improvement in patients treated with orthognathic surgery than with botulinum toxin application.

Botulinum toxin for 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.

Background: The pursuit of esthetic excellence has become a major goal in the dental treatment. Gummy smile is one of the complaints of the patients, since such a situation can influence self-esteem and social relationships. The beauty of the smile is not only constituted by the shape, position and size of the teeth, but also based on the characteristics of the gingival tissue and conformation of the lips, which should be as harmonious as teeth. The development of new more conservative techniques may provide a better therapeutic option than surgical procedures, such as the application of botulinum toxin, in the treatment of gummy smile. Purpose: to present the case of a patient who presented dentogingival discrepancy caused by gingival overgrowth and gummy smile, treated by gingivoplasty and complemented by application of botulinum toxin. Description of the case: The gingivoplasty was performed followed by the application of botulinum toxin type A. Results: The gingivoplasty resulted of the improvement of gingival arches and the application of botulinum toxin promoted the dehiscence of upper lip, reducing the gingival exposure. Conclusions: The application of botulinum toxin, associated with gingivoplasty, is an important tool at the management of gummy smile, optimizing smile harmony and achieving improved self-esteem and quality of life.

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. 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. A 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. 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. The 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.

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.