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.

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 for gummy smile correction

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.

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

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.

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.

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.

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, the search for esthetic excellence has become the main objective in the facial treatment. The gummy smile is one of the complaints from the patients, since this situation may influence their self-esteem and social relationship. The development of new techniques, such as the application of botulinum toxin, may be a conservative therapeutic option in the treatment of gummy smile. The purpose of this letter is to comment some points about a case report publicated in Dermatology Online Journal, of a patient with dentogingival discrepancy and severe gummy smile, who was treated with application of botulinum toxin in order to optimize the harmony of the smile.

Background: Modified lip repositioning operation (MLR) are being used very frequently in recent times for treating Gummy Smile (GS) caused by hyperactive upper lip as they are easily applicable, have very few side effects and high patient satisfaction. The purpose of this study is to assess whether or not the effects of MLR operation that is used in GS treatment is temporary. Methods: In this study, 16 female patients who had complaints of excessive visibility of their gums while smiling were treated by MLR operations. The amounts of visibility of the gums were measured before the operation and in the 3rd and 6th months following the operation.Results: According to the measurements that were made and analysis that was carried out, the mean amounts of visible gums before the operation, 3 months after the operation and 6 months after the operation among the 16 patients were respectively 4.93±0.85 mm, 1.06±0.98 mm and 2.87±0.8 mm. The mean amount of reduction in the amounts of the visible gums after the operation were respectively 3.75±0.93 mm and 2.06±0.68 mm for the 3rd and 6th months after the operation. Conclusions: Based on the results of this study, we may state that the effects of the MLR operation on the amount of visible gums while smiling decrease in time. However, the fact that the study was carried out on a few patients prevents us from reaching precise conclusions about this topic. As the authors, we recommend that similar studies are carried out with larger samples, and for the purpose of restricting lip movements, Botulinum Toxin is applied 2 weeks before the operation.

In many cases, the cause of a gummy smile is a combination of many simultaneously occurring factors. Therefore, a single method is certainly not effective in achieving the maximum aesthetic requirements. This study aims to evaluate the efficacy of combining clinical tooth crown lengthening surgery and subsequent BTX-A injection in gummy smile treatment using clinical and photographical assessment. 21 patients with an average length of excessive gingival display of at least 4 mm at maximum smiling point and with the height of keratinized gingiva ≥ 3 mm were recruited. Gingival exposure (GE) and clinical crown length (CCL) were measured at baseline (T0), two months after clinical crown lengthening surgery (T1), two weeks after BTX-A injection (T2), two months after BTX-A injection (T3). GE values at T1, T2 and T3 were significantly different (p &lt;0.001). CCL was significantly changed after gingivectomy surgery (T1) compared to preoperative value (T0) (p &lt;0.001). BTX-A could be considered a favorable adjunctive treatment for gummy smile patients after gingivectomy surgery.

An unpleasant smile can have a psychosocial effect leading to lack of self-esteem and a challenge in social relations. A perfect smile is a balance among 3 parameters: the white (teeth), the pink (gum) and the lips. A predictable smile correction warrants a multidisciplinary approach and good treatment planning. We planned for a minimally invasive interdisciplinary treatment approach for the restoration of a gummy smile with dental fluorosis in a young female patient. An interdisciplinary management of smile correction is crucial for successful results. Lasers for soft tissue management and minimal tooth preparation for direct composite veneer restorations being minimally invasive periodontal and restorative approaches were the key to success with exceptional patient satisfaction. Minimally invasive procedures in interdisciplinary dentistry should be embraced in the management of procedures requiring correction of both hard and soft tissues, for successful outcomes. Pre-treatment mock-up can build patients' confidence in dentistry and are useful tools for planning treatments with a predictable outcome. A beautiful smile is the fruit of a coordinated and balanced interplay between teeth, gingiva and lips. A compromise in any of these cornerstones can impair the beauty of a smile. Thorough knowledge and understanding about the various elements involved and their harmonious synchronisation makes smile makeovers a challenging task. One such challenge is the treatment of gummy smile. A gummy smile is a clinical condition that has gained tremendous focus and attention recently. Gummy smile is the excessive gingival display when a person smiles. It has been defined as a nonpathological condition causing aesthetic disharmony in which more than 3 mm of gingival tissue is exposed while smiling.1 Aetiology of a gummy smile can be multifactorial and the main factors being altered passive eruption (APE), vertical maxillary excess and upper lip hypermobility. The diagnosis must be accurate to deliver the appropriate line of treatment. Based on the complexity of the underlying aetiological factors involved, the treatment modalities also change from conservative approaches like aesthetic restorations and orthodontic tooth movements to periodontal and maxillofacial surgical procedures.2 Altered passive eruption (APE) also knows as “impaired passive eruption” is a clinical condition characterised by the coronally positioned marginal gingiva in relation to the cementoenamel junction (CEJ). Passive eruption is a physiological phase involved in the process of tooth eruption. As the teeth meet the occlusal plane, the soft tissue covering the teeth migrates apically till the CEJ is reached. Retardation in this process causes failure of the gingiva to migrate apically, resulting in short clinical crowns and excessive soft tissue exposure while smiling. This is visualised as a gummy smile.

Background: Excessive gingival display, or “gummy smile,” occurs in up to 14% of adults and is associated with lip hyperactivity, dentoalveolar extrusion, or vertical maxillary excess. Botulinum toxin A (BTA) has emerged as a minimally invasive therapeutic option, but protocols vary widely and long-term data are limited. Objectives: To critically evaluate the current literature on BTA in gummy smile management, focusing on classification systems, injection techniques, efficacy, safety, and comparative outcomes against conventional surgical and orthodontic treatments. Methods: A narrative review was performed using PubMed, MEDLINE, and Scopus (2000-2023) with the terms “gummy smile,” “excessive gingival display,” and “botulinum toxin.” Clinical studies, case series, and reviews addressing BTA use were included. Data were synthesized into thematic categories. Results: BTA consistently reduced gingival exposure by 3 to 5 mm, with effects lasting 4 to 6 months. Three main injection strategies were identified: single-point (Yonsei), multi-point, and orbicularis oris (“lip flip”). Reported complications were rare and transient (mild asymmetry, lip weakness). Standardized protocols were lacking, with heterogeneity in dosing (2-5 units per site) and injection depth. Comparative studies suggested BTA is less durable than surgical approaches but offers superior patient acceptability and safety for mild to moderate cases. Conclusion: BTA provides reproducible, temporary improvement in gummy smiles with high safety and satisfaction rates. However, absence of consensus on optimal technique and limited long-term evidence highlight the need for standardized protocols and prospective multicenter studies.

The harmony of the smile depends not only on the dentition, but also on the gum tissue, which excessively exposed can negatively affect aesthetics of the smile. Exposure of a small amount of gum during a smile is acceptable however a smile in which the exposure of the gum is more than 2 mm is considered an aesthetic defect called gummy smile. Among the causes of gingival smile listed are: shortened or hyperactive upper lip muscles (levator labii superioris, levator labii superioris alaeque nasi, zygomatic minor muscles), vertical maxillary excess, extrusion of alveolar ridges, altered passive eruption. In the case of hyperactive upper lip muscles, botulinum toxin can be used — this procedure was used in the described cases, and the effects were assessed using the FotoMedicus system and measurements of gingival exposure. In first case Bocouture botulinum toxin was administered on both sides, 4 units bilaterally in the levator labii superioris muscle and 2 units into levator anguli oris muscle. In total, 12 units were given. During the follow‑up the patient reported the start of the effect from the 5th day after the supply with the maximum effect after 12 days. A 6 mm correction of gummy smile was achieved. In the second case 4 units of botulinum toxin were applicated bilaterally into levator labii superioris alaeque nasi muscle. A 3 mm correction of gummy smile was achieved. The aesthetics of the face in a smile definitely improved in both men.