Is lip repositioning operation actually effective in treatment of gummy smile?

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

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.

Materials and Method: 60 patients who were diagnosed with DUB and were treated with either oral tranexamic acid 3gr/day or LNG-IUS were included in the study. Bleeding scores(PBAS), duration of bleeding and haemoglobin values before the therapy were recorded. Patients were evaluated again for the same parameters and possible side effects on the 3rd and 6th months of therapy. Results: Decrease in duration of bleeding on the 3rd and 6th months of therapy were statistically significant in both groups(p<0,05). While there was no statistically significant difference on the decrease in the duration of bleeding on the 3rd month of therapy(p>0,05), the decrease was more significant in the LNG-IUS group than the tranexamic acid group on the 6th month(p<0,05). In the tranexamic acid group, PBAS dropped by 55 % on the 3rd month, and 62% on the 6th month, but these changes were not significantly different from each other(p>0,05). In the LNG-IUS group, PBAS decreased by 87.5 % on the 3rd month, and 90.5% on the 6th month, and these changes were statistically significant(p<0,05). However, the decrease in the amount of bleeding was significantly more in the LNG-IUS group than the tranexamic acid group(p<0,05). While haemoglobin levels increased 5.6% on the 3rd month and 9.4% on the 6th month in the LNG-IUS group, they increased 3.6% on the 3rd month and 4.5% on the 6th month in the tranexamic acid group. In the LNG-IUS group the most common complaint was mastalgia on the 3rd month of therapy(40%, 10 patients), and oligomenorrhea-amenorrhea on the 6th month (43%, 10 patients). After 6 months, 78% of patients continued the treatment, while 2 patients(6.6%) quit the therapy because of the side effects. In the tranexamic acid group, the compliance rate was 63%, and none of the patients had discontinued the therapy due to side effects. Conclusion: Even though LNG-IUD is more effective than tranexamic acid in reducing blood loss in DUB patients, the major change in the menstrual cycle pattern and systemic side effects are the most common reasons for discontinuing therapy. Tranexamic acid reduces blood loss while conserving cycle patterns and fertility, and is better tolerated.

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.

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 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.

Does ligation of internal iliac artery for postpartum hemorrhage affect clitoral artery blood flow and postpartum sexual functions?

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.

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.

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

The removal of the ovaries for any reason causes surgical menopause. Hormonal changes that occur progressively over 5-10years in natural menopause occur acutely in surgical menopause. Signs of estrogen deficiency appear suddenly and are permanent after this surgery. This study investigated the short- and long-term effects of estrogen deficiency occurring after surgical menopause on both nasal mucociliary activity and sinonasal symptoms. This prospective study included women aged 20-45years who were not in the menopause, who had a planned bilateral oophorectomy and who attended the Gynecology Clinic at the Faculty of Medicine at a university hospital between January 2018 and December 2019. The nasal mucociliary clearance time, and blood Estradiol (E2) and FSH levels were measured once in the preoperative period, and at the postoperative 3rd, 6th, 9th, and 12th months. At the same times, the Sinonasal Outcome Test 22 (SNOT-22) was also applied. The average age of the 47 patients was 41.2 ± 2.7. The mean serum estradiol levels of the women were 164.7 ± 63.4pg/ml in the preoperative period, 14.8 ± 3.7pg/ml at the postoperative 3rd month, 12.5 ± 3.5pg/ml at the postoperative 6th month, 11.6 ± 3.0pg/ml at the postoperative 9th month, and 11.1 ± 2.7pg/ml at the postoperative 12th month. The mean FSH levels of the women were 9.4 ± 2.4 mIU/ml in the preoperative period, 60.5 ± 9.6 mIU/ml at the postoperative 3rd month, 61.9 ± 9.4 mIU/ml at the postoperative 6th month, 63.0 ± 9.3 mIU/ml at the postoperative 9th month, and 64.6 ± 8.7 mIU/ml at the postoperative 12th month. The changes in postoperative mean estradiol and FSH levels over a year were significant and consistent with menopausal symptoms (p < 0.001). The mean mucociliary clearance times were 12.6 ± 1.2 before menopause, 13.2 ± 1.7 at the postoperative 3rd month, 14.5 ± 1.7 at the postoperative 6th month, 17.5 ± 1.6 at the postoperative 9th month, and 19.4 ± 1.9 at the postoperative 12th month. The extension of the mean mucociliary clearance time over 1 year was significant (p < 0.001). The mean scores for the SNOT-22 were 17.3 ± 6.9 before the operation, 17.8 ± 6.0 at the postoperative 3rd month, 19.6 ± 6.9 at the postoperative 6th month, 23.4 ± 10.4 at the postoperative 9th month, and 36.1 ± 10.0 at the postoperative 12th month. The mean scores for rhinologic symptoms were 5.2 ± 1.9 (3-11) in the preoperative period, 5.7 ± 2.0 (3-12) at the postoperative 3rd month, 7.1 ± 2.3 (4-14) at the postoperative 6th month, 9.3 ± 3.3 (4-16) at the postoperative 9th month, and 11.9 ± 3.3 (6-18) at the postoperative 12th month. The 1-year change in the SNOT-22 scores was found to be significant (p < 0.001). After bilateral oophorectomy, menopausal hormonal values were acutely high in women. At the 1-year postmenopausal follow-up, the mean scores for the SNOT-22 had increased significantly. In other words, quality of life decreased in parallel with prolonged nasal mucociliary clearance time.

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.

Ischaemia-reperfusion injury (IRI) is a factor leading to the damages of the transplanted kidney, what affects mainly the proximal tubules. Early monitoring of tubule damage can be an efficient tool to predict the allograft dysfunction. Present in proximal tubules, N-acetyl-beta-glucosaminidase (NAG) is a lysosomal enzyme whose excretion rises as a result of IRI or acute rejection. The aim of this study was to monitor the NAG urine activity to evaluate the early proximal tubule damage, and to try to predict the long-term function of the transplanted kidney. The study enrolled 87 Caucasian renal transplant recipients (61.7% males, 38.3% females, mean age 45.56±14.34 years). Urine samples were collected for NAG and creatinine analysis on the 1st day after transplantation, and then in the 3rd and 12th month. Protocol biopsies were performed in the 3rd and 12th month. A significant positive correlation between NAG urine activity in the 3rd month after transplantation and creatinine concentration on the 14th (p=0.004) and 30th day (p=0.05), in the 3rd month (p=0.009) and after the 1st (p=0.005) and 2nd year (p=0.003) was observed. A statistically significantly higher urinary NAG activity in samples collected in the first 3 days and in the 3rd month after transplantation among patients with DGF (p=0.006 and p=0.03 respectively) was found. There was a significant positive correlation between NAG urine activity in the 3rd month and the grade of tubular atrophy in specimens collected in the 3rd (p=0.03) and 12th (p=0.04) month. Monitoring of NAG urine activity is useful in the evaluation of early proximal tubule damage and predicting the long-term function of the transplanted kidneys.

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Background/Aim: In patients with diabetes mellitus (DM), complications due to hyperglycemia decrease the quality of life and increase mortality. Vitamin D deficiency and thyroid dysfunction negatively affect blood glucose regulation. We aimed to demonstrate effects of treatment of vitamin D deficiency and thyroid dysfunction on blood glucose regulation. This study aimed to reduce the complications that may develop due to hyperglycemia. Methods: In this retrospective cohort study, Type 2 DM patients admitted to our clinic between 2015-2018 were reviewed from hospital registry. Patients who did not attend to their control visits for DM at the 0th, 3rd and 6th months and those with the exclusion criteria were not included. Patients who regularly attended diabetes controls at the 0th, 3rd and 6th months were determined. Among them, those with 25-hydroxy (OH) vitamin D, glycated hemoglobin (HbA1c), fasting blood glucose (FBG), postprandial blood glucose (PPG), free T4, free T3, thyroid stimulating hormone (TSH) values in the hospital registry were sought. Patients with vitamin D deficiencies and thyroid disorders who began treatment at the 0th month were finally included in the study, and the effects of vitamin D replacement treatment and thyroid dysfunction treatment on blood glucose regulation parameters at the 3rd and 6th months were examined. Results: HbA1c levels significantly decreased in Type 2 DM patients whose vitamin D levels were within normal limits at the 3rd month after receiving vitamin D replacement therapy (P=0.023). Vitamin D and HbA1c levels at the 3rd month controls were negatively correlated (r=-0.23, P=0.016, respectively). There were no significant differences in FBG and PPG levels at the 3rd month (P=0.063, P=0.361, respectively). In type 2 DM patients with hypothyroidism at the 0th month who were euthyroid at the 3rd month, there were no statistically significant differences in HbA1c, FBG and PPG (P=0.202, P=0.14, P=0.40, respectively). Six type 2 DM patients became euthyroid at the 3rd and 6th months after beginning levothyroxine treatment at the 0th month, and six patients became euthyroid at the 3rd and 6th months after hyperthyroidism treatment. Two patients had their FBG, and PPG values measured. Due to the insufficient sample size, statistical significance of differences in HbA1c, FBG and PPG levels could not be determined. Conclusion: Vitamin D replacement treatment had positive effects on blood glucose regulation in DM patients with vitamin D deficiency. The effects of vitamin D on blood glucose regulation should be evaluated by HbA1c. Thyroid dysfunctions were not sufficiently questioned during the three-month follow-up of DM patients, so its effects on blood glucose regulation could not be evaluated. Thyroid dysfunction should be questioned in the 3-month follow-up of DM patients and thyroid function tests should be requested.