Comparison of Effectiveness, Duration, and Patient’s Satisfaction of Botulinum Toxin A and Hyaluronic Filler in the Treatment of Gummy Smile: An in Vivo Study

Although energy devices and botulinum toxin A (BTX-A) can alleviate age-related laxity, ptosis and platysmal bands, they have limited efficacy on horizontal neck lines. The purpose of this study was to investigate the efficacy, safety and patient satisfaction of a combined treatment of non-crosslinked hyaluronic acid (HA) compound filling plus mesotherapy for the correction of horizontal neck lines, in comparison with BTX-A. This multicentre, randomized, evaluator-blinded, prospective study enrolled female patients with moderate-to-severe horizontal neck lines corrected with either two or three sessions of non-crosslinked HA compound filling plus mesotherapy or one session of BTX-A injection. Improvement of the neck lines grades, Global Aesthetic Improvement Scale (GAIS), patient satisfaction and adverse events (AEs) were evaluated and compared at 1, 3, 6 and 10 months after the final treatment. Twenty-five patients received HA filling plus mesotherapy and 23 received BTX-A injection. Compared with BTX-A, the HA compound filling plus mesotherapy significantly improved the horizontal neck line grades on all follow-up visits (P < 0.001). Patients with different baseline grades (2, 2.5 and 3) demonstrated similar outcomes. The GAIS and patients’ satisfaction ratings were significantly higher for the HA filling plus mesotherapy treatment group (P < 0.001). Significantly higher pain ratings, higher incidence and longer recovery of adverse events (erythema, oedema and ecchymosis) were noticed in the combined treatment group (P < 0.001). No serious adverse events occurred. Compared with BTX-A, combined treatment with HA compound filling plus mesotherapy significantly improved moderate-to-severe horizontal neck lines and achieved a high level of patient satisfaction.

BackgroundAlthough energy devices and botulinum toxin A (BTX-A) can alleviate age-related laxity, ptosis, and platysmal bands, they have limited efficacy on horizontal neck lines.ObjectivesThe purpose of this study was to investigate the efficacy, safety, and subject satisfaction of a combined treatment of non–cross-linked hyaluronic acid (HA) compound filling plus mesotherapy for the correction of horizontal neck lines, in comparison with BTX-A.MethodsThis multicenter, randomized, evaluator-blinded, prospective study enrolled female patients with moderate-to-severe horizontal neck lines corrected with either 2 or 3 sessions of of non–cross-linked HA compound filling plus mesotherapy or 1 session of BTX-A injection. Improvement of the neck lines grades, Global Aesthetic Improvement Scale (GAIS), patient satisfaction, and adverse events (AEs) were evaluated and compared at 1, 3, 6, and 10 months after the final treatment.ResultsTwenty-five patients received HA filling plus mesotherapy and 23 received BTX-A injection. Compared with BTX-A, the HA compound filling plus mesotherapy significantly improved the horizontal neck lines grades on all follow-up visits (P = 0.000). Cases of different baseline grades (2, 2.5, and 3) demonstrated similar outcomes. The GAIS and patients’ satisfaction ratings were significantly higher for the HA filling plus mesotherapy treatment group (P = 0.000). Significantly higher pain ratings, higher incidence, and longer recovery of AEs (erythema, edema, and ecchymosis) were noticed in the combined treatment group (P < 0.001). No serious AEs occurred.ConclusionsCompared with BTX-A, combined treatment with HA compound filling plus mesotherapy significantly improved moderate-to-severe horizontal neck lines and achieved a high level of patient satisfaction.Level of Evidence: 4

The objective is to determine the effect of oral zinc supplement intake on the clinical efficacy and sustained effect of BTXA injection, in patients with excessive gingival display (EGD). Twenty-five participants with excessive gingival display (EGD) were included in this parallel-group RCT, treated with BTXA with and without Zinc supplementation prior to treatment. Participants were assessed for excessive gingival display reduction and results of stability at 2, 6, 12, 18, and 24 weeks. Patient satisfaction questionnaires were filled at 2, 12, and 24 weeks. The results of this study revealed that after 6, 12, 18, as well as 24 weeks; The control group (BTXA) showed statistically significantly higher median gingival display than the intervention (Zinc supplement with BTXA). In the intervention group, the median gingival display after 24 weeks showed statistically significantly lower median value compared to the baseline measurement CONCLUSIONS: The use of zinc supplementation prior to BTXA injection prolonged its effect and maintained long-term decreased amount of gingival display, and it did not return to baseline measurements. Patients reported high satisfaction levels and self-confidence. Botulinum Toxin A (BTXA) is used to correct gummy smile; however, its main drawback is its short-lasting effect. Oral zinc supplement intake prior to BTXA injection could maintain the effect of BTXA and enhance its clinical efficacy.

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

Hyperfunction of the muscles of the upper lip is considered as the most common cause of excessive gingival display (EGD). The aim of this study was to demonstrate the effectiveness of botulinum toxin (BT) injection as a conservative treatment for EGD due to muscular hyperfunction and to compare the outcome of 2 injection methods. This study included 40 participants who were randomly assigned into 2 groups of 20 each, The first group received 2.5IU BT injection at 1 point per side (2-points group), while the second group received a total of 5 IU of BT at 2 points per side (4-points group). The outcome variables were the reduction in the central and lateral gingival display expressed as the difference between the pre- and post-injection measurements and the degree of satisfaction of the participants. The follow up visits were at 2- and 12-weeks postinjection. The study variables were statistically analyzed and probability values of <0.05 were considered significant. There was a significant improvement (P < 0.0001) in both groups throughout the follow up period, but the improvement achieved by 4-points group was significantly better than that of the 2-points group with respect to the gingival display and the degree of satisfaction (P < 0.0001). Botulinum toxin injection represents a safe and less invasive modality for treatment of EGD, the 4-points method results in better outcome in terms of clinical measurements and degree of satisfaction over the 2-points method.

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.

Botulinum toxin for gummy smile correction

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.

Treatment of hyperhidrosis

Authors' response

Excessive gingival display (EGD), or a gummy smile (GS), is a mucogingival deformity that can be of concern to patients. The prevalence of GS etiologies, such as altered passive eruption (APE) and hypermobile upper lip (HUL), has not been reported. The aim of this study was to assess the prevalence of APE and HUL in patients seeking to correct their GS, and to determine possible prevalence differences among patients with different gingival display (GD) levels. During clinical screening of patients interested in participating in a GS treatment study, GD diagnosis, GD level, and presence of APE and/or HUL were determined. Descriptive statistics were calculated for APE, HUL, and GD group prevalence. Fisher's exact test was used to determine difference in frequency of etiologies between GD groups. Fifty-six patients were clinically screened (27.2 ± 7.2 years old; 85.7% females; 94.6% with GD, 5.4% without GD). Among patients having GD, 75.5% presented with GD≥4mm and 24.5% with GD<4mm. Prevalence of etiologies was: 20.8% APE alone, 45.3% HUL alone, and 34% APE and HUL. The prevalence difference between GD≥4mm and GD<4mm groups was statistically significant (p<0.0001); for ≥4mm GD: 5% presented with APE alone, 50% HUL alone, and 45% APE and HUL; for<4mm GD: 69.2% presented with APE alone and 30.8% HUL alone. Among patients seeking GS treatment, HUL is the most predominant etiology and it is often present in combination with APE.

Background: A gummy smile (excessive gingival display) is a common aesthetic concern that disrupts the visual harmony between teeth, gingiva, and lips. Its etiology may be gingival, muscular, or skeletal. While multiple treatment modalities exist, selecting the optimal plan depends on accurate diagnosis of the underlying cause. Objective: To evaluate the effectiveness of combining gingivectomy and botulinum toxin injections in managing gummy smiles caused by altered passive eruption and hyperactivity of the upper lip elevator muscles, and to compare the outcomes with those reported in the literature. Materials and Methods: Diagnosis was established through clinical examination, panoramic radiography, and gingival measurements. An external bevel gingivectomy was performed without osseous recontouring, followed by botulinum toxin injections (2 units per side) at the Y-point. Outcomes were assessed in terms of aesthetic improvement, stability, and patient satisfaction. Results: The combined approach reduced gingival exposure and improved the crown-to-gingiva ratio, achieving high patient satisfaction. Findings were consistent with studies supporting the integration of surgery and botulinum toxin in multi-factorial cases. Botulinum toxin provided rapid but temporary improvement (4–6 months), while gingivectomy offered longer-lasting results in gingival-related cases. Conclusion: The combination of gingivectomy and botulinum toxin injections is an effective treatment option for gummy smiles of mixed etiology, provided that precise diagnosis and clear indications for each procedure are established. A multidisciplinary approach and well-defined diagnostic algorithms are recommended to ensure optimal aesthetic and functional outcomes.

Background: A gummy smile (excessive gingival display) is a common aesthetic concern that disrupts the visual harmony between teeth, gingiva, and lips. Its etiology may be gingival, muscular, or skeletal. While multiple treatment modalities exist, selecting the optimal plan depends on accurate diagnosis of the underlying cause. Objective: To evaluate the effectiveness of combining gingivectomy and botulinum toxin injections in managing gummy smiles caused by altered passive eruption and hyperactivity of the upper lip elevator muscles, and to compare the outcomes with those reported in the literature. Materials and Methods: Diagnosis was established through clinical examination, panoramic radiography, and gingival measurements. An external bevel gingivectomy was performed without osseous recontouring, followed by botulinum toxin injections (2 units per side) at the Y-point. Outcomes were assessed in terms of aesthetic improvement, stability, and patient satisfaction. Results: The combined approach reduced gingival exposure and improved the crown-to-gingiva ratio, achieving high patient satisfaction. Findings were consistent with studies supporting the integration of surgery and botulinum toxin in multi-factorial cases. Botulinum toxin provided rapid but temporary improvement (4–6 months), while gingivectomy offered longer-lasting results in gingival-related cases. Conclusion: The combination of gingivectomy and botulinum toxin injections is an effective treatment option for gummy smiles of mixed etiology, provided that precise diagnosis and clear indications for each procedure are established. A multidisciplinary approach and well-defined diagnostic algorithms are recommended to ensure optimal aesthetic and functional outcomes.

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.