MANEJO DO SORRISO GENGIVAL ATRAVÉS DO USO DA TOXINA BOTULÍNICA TIPO A

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

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.

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.

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 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.

Botulinum toxin for gummy smile correction

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.

Stuttering is a psychosomatic condition with a high degree of social dysfunction characterized by involuntary interruptions in the flow of speech. The etiology is considered to be multifactorial. Speech therapy is the first-line treatment, and therapeutic alternatives have been proposed with different pharmacological agents. In this case report, we describe the use of botulinum toxin type A (BTX-A) in the facial muscles for treating a patient with developmental stuttering which showed a significant temporary improvement after undergoing the procedure. This is a single-subject study. In the current medical literature, there are a few descriptions of using BTX-A injections in the intrinsic laryngeal muscles with favorable results, but no reports of its use in facial muscles for the treatment of stuttering. Therefore, this report may be important to highlight BTX-A as a safe and effective option when managing to stutter. Hopefully, it will assist in the search for effective treatment and form part of the multi-disciplinary approach in the treatment of stuttering, helping these patients to reduce their social dysfunction and improve their speech and their lives.

Demand for less-invasive procedures for treating gummy smile, such as botulinum toxin A injections, has increased substantially over the years. Meanwhile, the optimal injection site for botulinum toxin A injection is debated. The authors aimed to investigate the efficacy of botulinum toxin A injection at the Yonsei point for treating gummy smile. In this double-blind, single-site, randomized clinical trial, healthy participants with a gummy smile (anterior gingival exposure of ≥3.0 mm) were enrolled and randomized (1:1 ratio) into two groups. The experimental group was administered 6 U of botulinum toxin A at the Yonsei point (a single-site injection of 3 U to the right Yonsei point and 3 U to the left Yonsei point), and the control group received the same dose in the bilateral levator labii superioris alaeque nasi muscle sites. The patients were assessed at baseline and 4, 12, 24, and 48 weeks after the first injection using a digital vernier caliper. A total of 49 participants were enrolled. Anterior and bilateral posterior gingival exposure were reduced at 4, 12, and 24 weeks ( P ≤ 0.05) and returned to baseline at 48 weeks in both groups; there was no difference between the groups at these time points. The increase in satisfaction among patients was significant, and few adverse events were observed. Both the Yonsei point and the levator labii superioris alaeque nasi muscle site can be used as botulinum toxin A injection sites for treating gummy smile. Therapeutic, I.

Aims: To analyze and understand the neurological side effects associated with long-term use of botulinum toxin type A (BoNT-A), highlighting its implications on motor and sensory function in patients undergoing prolonged therapeutic application. Study Design: Qualitative exploratory-descriptive bibliographic review. Place and Duration of Study: The study was conducted using data collected from scientific literature indexed in PubMed, SciELO, and the Virtual Health Library (VHL), covering publications from 2013 to 2023. Methodology: A systematic search was performed using controlled descriptors such as Neurological Side Effects, Botulinum Toxin, Central Nervous System, and Peripheral Nervous System. Boolean operators “AND” and “OR” were applied to refine the search. Inclusion criteria focused on full-text articles in English, Portuguese, and Spanish that directly addressed the neurological impacts of BoNT-A. The review excluded duplicated materials, summaries, debates, and inaccessible content. The selected studies were analyzed through three axes: identification of neurological side effects, impacts on motor and sensory function, and mechanisms of influence on the central nervous system. Results: Findings indicated that BoNT-A is generally effective and safe for motor conditions such as spasticity and facial paralysis, though long-term use may result in mild to moderate adverse effects, including fatigue and muscle weakness. In chronic migraine treatment, BoNT-A showed significant improvement in pain frequency and quality of life. Potential retrograde transport of the toxin suggests central nervous system involvement. Statistical values were not derived as this was a literature-based review, but recurrent patterns across studies support the findings. Conclusion: Botulinum toxin type A remains a valuable therapeutic option; however, prolonged administration requires caution and individualized monitoring. Further research is necessary to fully understand its central mechanisms and to establish safer, optimized protocols for long-term neurological applications.

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.

Accessible online at: www.karger.com/journals/ene Therapeutic use of botulinum toxin type A (BT-A) has dramatically increased after its introduction by Scott [1] in 1980. It now provides help for patients suffering from muscle hyperactivity disorders in neurology, rehabilitation medicine, pediatrics, otorhinolaryngology, ophthalmology, urology and many other areas. Recently, it has been recognised that its cholinergic blockade can also be used to reduce exocrine gland hyperactivity: the longsearched-for remedy for hyperhidrosis. With some evidence suggesting an analgetic effect in tension headache and migraine and with extension of its indications into the fashion world for removal of wrinkles, BT might look almost like a 19th century patent medicine. It certainly sells like one: worldwide BT-A sales soared to mind-boggling US$ 300 millions or so. Obviously, such a market attracts manufacturers. A new one has just arrived. With his product using botulinum toxin type B (BT-B) botulinum toxin therapy has now taken a new step. Do we need a new botulinum toxin product? Competition keeps the markets in good shape. With costs of around US$ 3,000 per year to treat a single torticollis patient vigorous competition is more than welcomed by the health economists. Do we need a new type of BT? So far, there has been no reason to believe that BT-B will work better than BT-A. With one exception: conventional BT preparations can induce antibody formation. This is a rare phenomenon, occurring in around 5% of torticollis patients. Not a large number, but, up to now, for most of those patients BT therapy was over. This is where BT-B comes in. Robust studies have demonstrated that BT-A antibodies do not inactivate BT-B [2]. This offers new hope to those patients. But questions remain to be answered: although statistical risk factors have been identified [3], therapy failure cannot be predicted. As a matter of fact, the activity of the individual patient’s immune system may well be the key factor. If this is true, antibody formation against BT-B would be imminent, especially given the high structural similarity between BT-B and BT-A. Whether these considerations will transform into a clinical problem we do not know. Only time will tell. When botulinum toxin therapy failure is unrelated to BT-A antibodies BT-B will not help. Reasons for unrelated therapy failure are numerous and considerable clinical experience is needed to identify them. BT-B cleaves the intracellular transport protein chain at a site different from BT-A [4]. It is not clear whether this matters therapeutically. Studies indicate that in torticollis patients between 7,500 and 10,000 mouse units of BT-B are needed to produce a reasonable therapeutic effect [5]. Similar therapeutic effects are seen after about 150–200 mouse units of Botox® [6] or about 500–750 mouse units of Dysport® [7]. This indicates a conversion factor for Botox® to BT-B in the order of 40–70 and for

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.

Background: Chronic migraine is a neurological disorder described as refractory to preventive treatments. Based on the PREEMPT study, the National Institute for Health and Clinical Excellence (NICE) and the FDA approved, in 2010, the use of Botulinum Toxin type A (BoNT/A) to treat refractory chronic migraine. Objectives: To review the effectiveness of the use of BoNT/A in the treatment of refractory migraine. Methods: Bibliographic review based on PubMed database, using the descriptors “migraine” and “botulinum toxin”. Clinical trials, meta-analyzes and randomized controlled tests, from the last five years, were defined as inclusion criteria. Results: Sanz et al., (2016) infiltrated BoNT/A in 69 patients - mean age 43 years old, 88.4% women, mean infiltration rate was 2,0. The reduction of headache days and pain intensity was 48.5% and 20.5%, respectively, both statistically significant (p <0.006). Ion et al., (2018) intervened 61 patients - mean age 50 years old, 87% women, mean infiltration of 3.5. 73% showed a reduction greater than 50% for the frequency of migraine episodes, 48% for headache days and 48% for drug use. Dodick et al., (2019) applied BoNT/A in 688 patients - 696 received placebo. The severity and frequency of pain showed a statistically significant reduction (p < 0.001) after the first week of treatment in relation to the control group. Conclusions: The use of BoNT/A to treat refractory chronic migraine proves to be effective, although there is need for studies with larger samples to ensure its effectiveness.

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.