Treatment of gummy smile: Nasal septum dysplasia as etiologic factor and therapeutic target

Introduction: Gummy smile is the excessive gingival display upon smiling. The main etiological factors associated with gingival smile include altered passive eruption, vertical maxillary excess and upper lip hyperfunction, and/or a combination of these. It has a psychological impact on some individuals, resulting in inconvenience, to a greater degree - unattractiveness and dissatisfaction in some patients. Management methods for the treatment of gingival smiles are invasive varieties of surgical approaches and non-invasive approaches described in the literature. Botox treatment is a new noninvasive approach and a conservative alternative to invasive surgical procedures. Results: The identification of nasal septum dysplasia as etiologic factor of gummy smile, propose a novel strategy for the improvement in the treatment of excessive gingival exposure. Studies indicate satisfactory results for patients with nasal septum dysplasia and gummy smile after surgical treatment for excessive gums by enhancing septal cartilage and, if necessary, additional lengthening with autologous cartilage grafting or expanded polytetrafluorescence (ePTFE) implant. Conclusion: The etiology of the gingival smile dictates the most appropriate treatment approach. This study regard a strategy of reinforcement and extension of nasal septum cartilage for the improvement of gummy smile confirming septal cartilage dysplasia as the etiologic factor.

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.

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.

Gummy smile, dermatologist or dentist?

Botulinum type A (BTX-A) injection is a promising treatment for gummy smile (GS), although its effects are varied and inconsistent. The aim of this study was to explore the effect of individual factors on BTX-A treatment for GS, and to establish treatment expectations. In this prospective clinical study, a standardized technique comprising bilateral single-point injections of 2 U BTX-A (total, 4 U) was administered to all GS patients. Data were collected at baseline and after 4, 12, and 32 weeks of follow-up. Twenty-nine potential individual factors were analyzed by correlation and regression analysis to exclude confounding bias. Ninety-four patients completed the BTX-A treatment. After adjusting for potential confounding factors, the correlation and regression analysis confirmed the following formula: anterior gingival exposure (GE) at 4 weeks = 1.44 + (0.94 × baseline anterior GE) - (1.88 × sex) (where male = 1 and female = 2). The confidence interval (CI) of the prediction showed that for all female participants with baseline anterior GE <5.3 mm, the 95% CI of anterior GE was 0.3 to 3.0 mm after 4 weeks of treatment, and 3.0 to 8.9 mm with baseline anterior GE ≥6 mm. For male patients with baseline anterior GEs of 3 and ≥4.6 mm, the 95% CIs were 1.5 to 3.3 mm and 3.2 to 8.9 mm, respectively. The effect of average-dose BTX-A treatment for GS depended on GS severity and patient's sex, rather than GS etiology and other factors. Female participants with baseline anterior GE <5.3 mm were more likely to show complete improvement after 4 weeks of treatment. However, female participants with baseline anterior GE ≥6.0 mm or male participants were less likely to show complete improvement at 4 weeks.

Excessive gingival display, or a "gummy smile," is defined as 2 mm or more of gingival exposure upon smiling. Such excessive gingival exposure can be aesthetically unappealing to patients. One factor that contributes to a gummy smile is hyperfunctional lip elevator muscles. The authors evaluate onabotulinumtoxinA as a safe and minimally invasive treatment for a gummy smile. In this prospective study, 14 patients (13 women, 1 man) underwent pretreatment photographs and measurements, followed by bilateral injection of onabotulinumtoxinA into their lip elevator muscles. All patients selected for the study had more than 2mm of gingival show and were classified as having a "cuspid smile," where action of all elevator muscles raised the upper lip- like a window shade-to expose the upper teeth and gingival scaffold; these patients were thought to have a better chance for a more superior result. Repeat measurements and photographs were collected at 2 weeks and 3 months. Patient-reported outcomes were collected at 2 weeks, and data were compared to determine the correlative relationship. An average of 5 units (range, 4-6 U) of onabotulinumtoxinA were injected into 3 sites bilaterally. The average preinjection gingival show over the central incisors and canines were 4.89 mm and 4.25 mm, respectively. Postinjection gingival show decreased to an average of 0.75 mm (85% improvement) and 0.74 mm (83% improvement) over the central incisors and canines, respectively. Average follow-up time was 12.6 days. One patient felt the resulting smile was unattractive and opted not to undergo repeat injections, while all other study participants experienced no negative effects and wished to undergo repeat treatment. As treatment for a "gummy smile," onabotulinumtoxinA provides an effective, minimally invasive, and safe therapy. This treatment option can lead to significant improvement in smile aesthetics with high patient satisfaction. 3.

Evaluation of the internal dual muscle traction approach as an adjunct to the modified surgical lip repositioning method: A randomized clinical report

The gingival smile is an aesthetic concern that affects a large portion of the population, an aesthetically acceptable smile must be harmonious as to the set of teeth, lips and gingival tissue. When the etiological factor is muscle hyperfunction, a treatment option is the application of botulinum toxin type A in the muscles responsible for lifting the upper lip, so the objective of this case report is to demonstrate the use of botulinum toxin to correct gummy smile. . Female patient, age 32, Phototype II, sought care at the Specialization Clinic in Orofacial Harmonization of the IOA-IOP, Campina Grande-PB, due to excessive gingival exposure when smiling. After clinical evaluation, it was observed that the patient had hyperactivity of the levator labii superioris muscles and a gingival exposure of 4 mm. It was proposed to the patient the application of botulinum toxin for the treatment of gummy smile and then the Free and Informed Consent Term was signed specifying all possible complications that could happen, as well as the benefits and results. After the photographs and demarcations, 2 units were applied to the levator labii superioris muscle bilaterally and 2 units to the nasal septum. After 15 days of application, the patient was reassessed, demonstrating an excellent result without excessive exposure of the gingiva and there was no need for a new application. It was concluded that TBA brought a very satisfactory result for the correction of the gummy smile and constitutes a safe and effective treatment.

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.

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.

The gingival smile is considered unpleasant and can be treated in different ways according to its etiological factor. When caused by maxillary vertical growth excess, orthognathic surgery may be indicated to correct the vertical excess. The aim of this integrative review was to evaluate the impact of orthognathic surgery on the treatment of gingival smile. An electronic search was performed of the PubMed/Medline, Cochrane Library, Scopus, and Google Scholar databases. The selection of studies was performed by two blinded reviewers. Firstly, studies were selected by reading the titles and the abstracts of articles. The references from each study selected were then searched to find articles that were not found in the electronic search. After reading the full-text articles, studies that met the inclusion criteria were selected. A total of 667 studies were identified, but only 19 were selected for the integrative review after applying the inclusion and exclusion criteria. The selected articles reported maxillary impaction from 2 to 10 mm, but this amount of superior repositioning of maxilla does not appear to be related to the initial gingival exposure described. Orthognathic surgery is not the first choice of treatment for gingival smile, but it appears to be a suitable therapy for other conditions in the same patient for improving a gummy smile by correction of gingival exposure.

Botulinum toxin for gummy smile correction

Treatment of excessive gingival display usually involves procedures such as Le Fort impaction or maxillary gingivectomies. The authors propose an alternative technique that reduces the muscular function of the elevator of the upper lip muscle and repositioning of the upper lip. Fourteen female patients with excessive gingival exposure were operated on between February of 2008 and March of 2009. They were filmed before and at least 6 months after the procedure. They were asked to perform their fullest smile, and the maximum gingival exposures were measured and analyzed using ImageJ software. Patients were operated on under local anesthesia. Their gingival mucosa was freed from the maxilla using a periosteum elevator. Skin and subcutaneous tissue were dissected bluntly from the underlying musculature of the upper lip. A frenuloplasty was performed to lengthen the upper lip. Both levator labii superioris muscles were dissected and divided. The postoperative course was uneventful in all of the patients. The mean gingival exposure before surgery was 5.22 +/- 1.48 mm; 6 months after surgery, it was 1.91 +/- 1.50 mm. The mean gingival exposure reduction was 3.31 +/- 1.05 mm (p < 0.001), ranging from 1.59 to 4.83 mm. This study shows that the proposed technique was efficient in reducing the amount of exposed gum during smile in all patients in this series.

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.

Gummy Smile, or excessive gingival display, is a clinical condition characterized by an overexposure of the maxillary gingiva during smiling, typically exceeding 3 mm. Although not pathological, this condition can lead to aesthetic discomfort and negatively impact the patient's self-esteem. In a normal, aesthetically pleasing smile, gingival exposure—defined as the distance between the lower margin of the upper lip and the cervical area of the upper central incisors—should not exceed 1–2 mm.1 Gummy Smile affects approximately 10% of individuals aged 20–30, with a higher prevalence among females.2 This condition has a multifactorial etiology, with each causative factor potentially acting independently or in combination with others, thereby complicating both the clinical presentation and case management.3 The main causes of excessive gingival exposure include: 1. Altered passive eruption (APE) 2. Dentoalveolar extrusion 3. Vertical maxillary excess (VME) 4. Gingival hyperplasia 5. Short upper lip 6. Hypermobility of the upper lip4 This study presents a systematic review of the scientific literature on therapeutic approaches for the treatment of Gummy Smile, offering a qualitative analysis of clinical indications, procedural techniques, aesthetic and functional outcomes, duration of results, post-treatment recovery, possible complications, and patient satisfaction. Based on the emerging evidence, a clinical decision-making algorithm has been developed to guide clinicians in the selection and management of Gummy Smile cases, according to their etiological profile. This algorithm is proposed