BOTULINUM TOXIN FOR CORRECTION OF GINGIVAL SMILE

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.

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.

Management of excessive gingival display using botulinum toxin type A: a descriptive study

We aimed to evaluate laypeople’s visual perception of the gingival smile before and after botulinum-toxin application, using eye-tracking technology. Two frontal photographs of a female volunteer’s face with a gingival smile were used. One before and another 30 days after the toxin application in the upper lip elevator muscle region. The images were evaluated by 58 participants. Using the OGAMA software, visualization data were obtained in three areas of interest (AOI) through eye-tracking. A visual analog scale (VAS) was used to assess facial attractiveness, and a questionnaire to assess the perception of sympathy, satisfaction with the smile, dissatisfaction with dental and gingival exposure, and shyness. Heat and point maps showed that the participants visually concentrated on the mouth region, with a small transition to the nose and eyes in the pre-procedure image. The mouth region was the AOI where the first visualization occurred in a shorter time compared to the latter areas (p<0.05). VAS revealed that attractiveness increased in the image with less gingival exposure (p<0.05). After the toxin application, satisfaction with the smile increased (p<0.05), and dissatisfaction with gingival exposure decreased (p<0.05). However, dissatisfaction with dental exposure increased (p<0.05). We discovered that the mouth attracted greater attention from participants in less time compared to other AOI. The decrease in gingival exposure after the botulinum toxin application resulted in improved facial esthetics. There was a perceptible increase in “satisfaction with the smile” and a decrease in “dissatisfaction with gingival exposure.” Conversely, the “dissatisfaction with dental exposure” increased.

Gummy smile is one of the major complaints of patients, due to its influence on the self-esteem. It is known that it has a multifactorial cause and can be present in the excessive vertical growth of the maxilla, excessive labial contraction, short upper lip and extrusion of the anterior teeth. The use of the botulinum toxin can be associated with additional treatments or be applied individually, according to the need of each patient. The goal of this research study was to present a clinical case using botulinum toxin type A as an alternative therapy to correct the gummy smile. A 22-year-old patient, presenting vertical maxillary growth, reporting aesthetic discomfort while smiling, chose for an alternative treatment therapy with the application of botulinum toxin to correct the accentuated gingival display. The results show that the toxin is a satisfactory treatment option and its indication is considered a fast, effective, easy and safe treatment method, being a more conservative approach compared to surgical procedures.

Botulinum toxin for gummy smile correction

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.

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.

Gummy smile is a condition characterized by excessive exposure of the gums during smiling. The demand for treatment for this condition has increased in recent years, and numerous techniques have been reported to treat gummy smile, such as gingivectomy, orthognathic surgery, lip repositioning surgery, and botulinum toxin injections. The objective of the work was to answer the guiding question: “What is the effect of botulinum toxin type A in the management of excessive gingival exposure – gummy smile?”. The databases Pubmed, Scielo and LILACS were used. The search was carried out in an advanced form, considering the descriptors: botulinum toxin, gummy smile, gum, botox and minimally invasive procedures. The inclusion criteria used were complete articles available in full, in the listed databases, published in the last 5 years in Portuguese, English and Spanish languages. Off-topic publications; in vitro and animal studies, literature reviews, theses, monographs and book chapters were excluded. 143 articles were retrieved, of which 77 were excluded due to duplication. After analyzing the titles and abstracts, 17 works were selected. At the end of the selection, 11 articles were included after reading the full text. It was concluded that the application of botulinum toxin is a safe and effective procedure for managing excessive gummy smile. It presented low rates of complications and high levels of satisfaction among patients. However, the patient must be aware that the clinical effect of botulinum toxin is temporary and requires periodic touch-ups to maintain the desired result. Keywords: Botulinum toxin. Gummy smile. Gingiva. Botox. Minimally invasive procedures.

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.

An aesthetically pleasing smile results from the combination of several factors, such as the position, size, shape, and color of the teeth, as well as the exposure and characteristics of the gingival tissue. When evaluating the gingival tissue in a smile, several important factors must be considered: excessive vertical growth of the maxilla, reduced length of the upper lip, excessive contraction of the upper lip, and disproportion between the length and width of the clinical crown of the anterior teeth. A minimally invasive approach that can be used as a complement to dental treatment is the application of botulinum toxin, a neurotoxin produced by the anaerobic bacterium Clostridium botulinum. This toxin blocks the release of acetylcholine in the presynaptic vesicles of neuromuscular junctions, inhibiting muscle contraction. The aim of this literature review was to analyze the use of botulinum toxin type A (BTX-A) in the management of gummy smile. The search was conducted in the databases Google Scholar, PubMed, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO). The descriptors used for the search were "botulinum toxin," "gingiva," "periodontology," and "dental aesthetics," combined using the boolean operators AND and OR. Although the evidence demonstrates favorable results, the use of botulinum toxin to correct gummy smile has limitations. It is a temporary solution, and patients should be informed about the need for periodic reapplications and the potential side effects, such as facial asymmetries. The reviewed studies indicate that this technique is particularly effective in cases of gummy smile resulting from hyperactivity of the upper lip elevator muscle, providing a significant reduction in gingival exposure, with results lasting up to 12 weeks. The combination of different therapeutic approaches, along with a careful evaluation of the causes of gummy smile, allows dental professionals to offer more integrated and personalized solutions for each patient.

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

Gummy Smile Correction Using Botulinum Toxin With Respective Gingival Surgery

Treatment of gummy smile: Nasal septum dysplasia as etiologic factor and therapeutic target

Excessive gingival display is a problem that can be managed by variety of procedures. These procedures include non-surgical and surgical methods. The underlying cause of gummy smile can affect the type of procedure to be selected. Most patients prefer minimally invasive procedures with outstanding results. The authors describe a minimally invasive lip repositioning technique for management of gummy smile. Twelve patients (10 females, 2 males) with gingival display of 4 mm or more were operated under local anesthesia using a modified lip repositioning technique. Patients were followed up for 1, 3, 6 and 12 months and gingival display was measured at each follow up visit. The gingival mucosa was dissected and levator labii superioris and depressor septi muscles were freed and repositioned in a lower position. The levator labii superioris muscles were pulled in a lower position using circumdental sutures for 10 days. Both surgeon's and patient's satisfaction of surgical outcome was recorded at each follow-up visit. At early stage of follow-up the main complaints of patients were the feeling of tension in the upper lip and circum oral area, mild pain which was managed with analgesics. One month postoperatively, the gingival display in all patients was recorded to be between 2 and 4 mm with a mean of (2.6 mm). Patient satisfaction records after 1 month showed that 10 patients were satisfied with the results. Three months postoperatively, the gingival display in all patients was recorded and found to be between 2 and 5 mm with a mean of 3 mm. Patient satisfaction records showed that 8 patients were satisfied with the results as they gave scores between. Surgeon's satisfaction at three months follow up showed that the surgeons were satisfied in 8 patients. The same results were found in the 6 and 12 months follow-up periods without any changes. Complete relapse was recorded only in one case at the third postoperative month. This study showed that the proposed lip repositioning technique is an acceptable minimally invasive procedure in managing gummy smile. A non-invasive procedure to avoid other complicated surgical procedures.