Botulinum toxin type A for the treatment of excessive gingival display – A systematic review

Botulinum toxin for gummy smile correction

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.

Botulinum toxin injection to treat a gummy smile: A few observations

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

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.

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.

The objective of this article is to review ideal injection point and ideal dose of botulinum toxin-A injections to treat different types of gummy smile, and to present a case treated with the recommended method. An electronic search of literature was carried out by using PubMed, Embase, and Google Scholar. Reference lists of studies were also hand-searched for relevance. According to inclusion and exclusion criteria, five prospective studies with 135 subjects were included in this systematic review. Injection of botulinum toxin-A is a noninvasive and temporary treatment option for gummy smile, and the Yonsei point is a safe and reproducible injection point for treatment by practitioners of all types of gummy smile.

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.

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

Chronic pain following amputation is debilitating. Due to its mechanisms in modulating muscle contraction and pain, botulinum toxin has been investigated as a treatment option for phantom limb pain (PLP) and residual limb pain (RLP). The objective of this study was to determine the efficacy of botulinum toxin injection in the management of PLP and RLP following major limb amputation using a systematic review of the literature. The databases Medline, CINAHL, EMBASE, Scopus, Web of Science, and Cochrane were searched from inception through October 30, 2023. The search identified 50 articles; 37 underwent full-text review, and 11 were included in the final review. Eighty-nine individuals with pain were investigated by the included studies; 53 had RLP and 63 had PLP. There was significant variation in botulinum toxin type, injection method, and dosage. Twenty-one (53.9%) and 27 (64.3%) participants had improvement in PLP and RLP following botulinum toxin injection, respectively. Therefore, there is potential for use of botulinum toxin for the treatment of PLP and RLP. However, due to the minimal number of studies, small sample sizes, and heterogenous methodologies, our ability to conclude with certainty the efficacy of botulinum toxin injection on the treatment of PLP and RLP following amputation is limited.

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.

A gummy smile is an excessive exposure of the gums while smiling. There are four types: anterior- excessive gum exposure from canine to canine, posterior — excessive gum exposure in the lateral segment, mixed — combining the anterior and posterior components, and asymmetrical — with a disproportion between the right and left side. The causes of gingival smile include: skeletal defect, delayed passive tooth eruption, nasal septal dysplasia, and excessive muscle activity. A simple, fast and minimally invasive method of gummy smile therapy caused by excessive muscle activity is the supply of botulinum toxin type A to the muscles responsible for a given type of smile. A favorable aesthetic effect can be achieved with a good knowledge of application sites and individually selected doses. When determining the dose, which is described in the literature between 2 IU and 10 IU onabotulin per page, researchers take into account not only the type of corrected smile, the number of puncture points, but also gender and age of the patient.

A gummy smile is an excessive exposure of the gums while smiling. There are four types: anterior- excessive gum exposure from canine to canine, posterior — excessive gum exposure in the lateral segment, mixed — combining the anterior and posterior components, and asymmetrical — with a disproportion between the right and left side. The causes of gingival smile include: skeletal defect, delayed passive tooth eruption, nasal septal dysplasia, and excessive muscle activity. A simple, fast and minimally invasive method of gummy smile therapy caused by excessive muscle activity is the supply of botulinum toxin type A to the muscles responsible for a given type of smile. A favorable aesthetic effect can be achieved with a good knowledge of application sites and individually selected doses. When determining the dose, which is described in the literature between 2 IU and 10 IU onabotulin per page, researchers take into account not only the type of corrected smile, the number of puncture points, but also gender and age of the patient.

Botulinum toxin for a gummy smile

IntroductionThe purpose of this study is to establish the efficacy of Yonsei point in the treatment of a gummy smile in a White South African population. The accurate surface anatomy criteria in relation to the underlying musculature for the administration of Botulinum toxin injections in the treatment of gummy smile was determined.Materials and MethodsNineteen (10 males and 9 females) cadavers were selected for facial dissection. Facial profile photographs were taken before and after dissection. The before and after photographs were overlayed to determine where the pin positions should be on the dissected cadaver to determine the Yonsei point. The levator labii superioris (LLS), LLS alaeque nasi (LLSAN), zygomaticus minor, and zygomaticus major muscles were measured using a protractor and ruler, which accounted for the manual measurements. Digital measurements were measured by importing dissected images into ImageJ. Circles with a 2 cm diameter (1 cm radius) were constructed to determine whether the Yonsei point could successfully influence muscles fibers.ResultsDigital and manual measurements show comparable results with high correlation and reliability. Results showed that the White South African population had narrower facial musculature angles as compared with the Korean population.ConclusionBased on the selected sample, the Yonsei point is an ineffective injection site for the successful treatment of gummy smile in a White South African population.