Gummy smile and botulinum toxin: A new approach based on the gingival exposure area

doi:10.1016/j.jaad.2010.02.053

Journal of the American Academy of Dermatology

Volume 63, Issue 6, December 2010, Pages 1042-1051

https://doi.org/10.1016/j.jaad.2010.02.053 Get rights and content

Background

Gummy smile (GS) is an aesthetic disorder for some patients, which can be corrected by injection of botulinum toxin.

Objective

We sought to classify GS according to the area of gingival exposure and the respective muscles involved in order to perfect the botulinum toxin injection technique for each patient.

Methods

Sixteen patients with GS were evaluated before receiving botulinum toxin injections. Based on the area of excessive gum displayed and identification of the muscles involved, 4 different types of GS were identified: anterior, posterior, mixed, and asymmetric. AbobotulinumtoxinA (Dysport, Ipsen Biopharm Limited, Wrexham, UK) was injected using a different injection technique for each type of GS, based on the main muscles involved. With the aid of two computer programs, the area of gum exposed was measured before and after the application of abobotulinumtoxinA, to evaluate the level of improvement.

Results

There was a decrease in the degree of gum display in all patients. The general average improvement achieved was 75.09%. Two patients showed slight adverse effects that were easily corrected with additional doses of abobotulinumtoxinA.

Limitations

For this study, there was no sample size calculation and no statistical analysis of the cases.

Conclusion

The authors conclude that it is important to identify the type of GS and therefore the main muscles involved, so that the correct injection technique can be used. AbobotulinumtoxinA was shown to be effective and safe for use in all types of GS in the present sample.

Section snippets

Methods

During a period of 20 months, 16 patients with GS were treated with applications of BT at a private practice. After the initial assessment, in which photographs were taken, we identified 4 different types of GS, based on the area of excessive gum displayed and identification of the main muscles involved (Table I): (1) anterior GS, in which more than 3 mm of gum is exposed in the area between the canine teeth–involving the action of the levator labii superioris alaeque nasi (LLSAN) muscles (3

Results

There was a decrease in the degree of gum display in all patients (Fig 7, Fig 8, Fig 9, Fig 10). Table II shows the type of GS and the percentage of decrease in gingival exposure before and after application of abobotulinumtoxinA in all patients in this sample. The average improvement achieved in all 16 patients was 75.09% and the average improvement in each group is shown in Table III. All the patients also had some degree of improvement to the nasolabial fold.

Adverse effects were mild and

Discussion

Since the discovery of the cosmetic use of BT,¹⁰ it has been rapidly incorporated into the arsenal of effective treatments for the improvement of unaesthetic facial conditions. During the more than two decades that BT has been used for cosmetic purposes, several new indications have been found and application techniques are being constantly refined.

In addition to being the first-choice treatment for wrinkles located on the upper third of the face, BT is also widely used in the prevention and

References (35)

N.C. Davis
Smile design
Dent Clin North Am
(2007)
M. Polo
Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile)
Am J Orthod Dentofacial Orthop
(2008)
A.H. Tjan et al.
Some esthetic factors in a smile
J Prosthet Dent
(1984)
M. Polo
Botulinum toxin type A in the treatment of excessive gingival display
Am J Orthod Dentofacial Orthop
(2005)
V. Gassia et al.
Botulinum toxin injection techniques in the lower third and middle of the face, the neck and the décolleté: the “Nefertiti lift.”
Ann Dermatol Venereol
(2009)
D.A. Garber et al.
The aesthetic smile: diagnosis and treatment
Periodontol 2000
(1996)
D.S. Gill et al.
Smile aesthetics
SADJ
(2008)
A. Carruthers et al.
Cosmetic uses of botulinum A exotoxin
A. Carruthers et al.
Botulinum toxin in the treatment of glabellar frown lines and other facial wrinkles
A.W. Klein
Dilution and storage of botulinum toxin
Dermatol Surg
(1998)

S. Karsai et al.

Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology

Dermatol Surg

(2009)

J. Coscarelli

Gingival smile

J.D.A. Carruthers et al.

Treatment of glabellar frown lines with C. botulinum-A exotoxin

J Dermatol Surg Oncol

(1992)

D. Hexsel et al.

Aplicações não-clássicas da toxina botulínica

J. Carruthers et al.

Botox treatment for expressive facial lines and wrinkles

Curr Opin Otolaryngol Head Neck Surg

(2000)

J.W. Robbins

Differential diagnosis and treatment of excess gingival display

Pract Periodontics Aesthet Dent

(1999)

Cited by (106)

Botulinum toxin type A for the treatment of excessive gingival display – A systematic review
2022, Journal of Stomatology, Oral and Maxillofacial Surgery
Citation Excerpt :
In cases of gingival exposure greater than 7 mm, Polo considers it preferable to perform a further injection of 2.5 U at the common insertion of the LLS and ZMi, since these severe cases often involve posterior exposure [26]. A prudent approach in treatment-naïve patients would be to inject small doses in a small number of sites, then perform an additional injection 2 weeks later if necessary both to complete the reduction of gingival display and correct possible asymmetries or compensation, notably from the depressor anguli oris (DAO) [22,27]. Regarding the duration of the effect, the analyzed studies show that the improvement in gingival display persists for 12 to 36 weeks.
Gummy smile has traditionally been treated with invasive or demanding surgical and orthodontic techniques. Several studies have shown that targeted injection of the upper lip elevator muscles with botulinum toxin is an effective treatment for this condition. However, no standardized injection protocol with reproducible results has yet been published.
A systematic review of the literature has been performed using Medline, Scopus, and Embase. All articles relevant to the research question were analyzed.
After removing duplicates, 162 articles were selected, of which 9 were included in the analysis after applying exclusion and inclusion criteria, for a total of 269 patients. Onabotulinum toxin type A (ONA-BoNTA) was used in 7 studies and abobotulinum toxin type A (ABO- BoNTA) in 2 studies, at various dilutions. The number of sites injected varied from 1 to 3 per side, with variable targeting of the Levator labii superioris alaeque nasalis, Levator labii superioris, Zygomaticus minor, Zygomaticus major and Orbicularis oris. The dose used per side varied from 1.25 to 6 U of ONA-BoNTA and from 2.5 to 7.5 U of ABO- BoNTA. The injection protocol was tailored to the type of gingival smile in one study only, another study compared results of targeting two different muscles, and one study evaluated different dosages of toxin for the same injection site. The average improvement ranged from 24.85% to 99.65% and the effect persisted from 12 to 36 weeks. Very good patient satisfaction was reported in 6 studies. Fourteen adverse events were reported, all of them mild and transient.
The treatment of gummy smile by botulinum toxin injection is effective, safe, rapid, minimally invasive and reversible. Protocols vary widely in the literature and no standardized procedure emerges. A patient-specific approach, adapted to their anatomy, type of gummy smile and the severity of the exposure seems to be the most appropriate. Randomized controlled studies are needed to make this approach more systematic.
Complications of facial cosmetic botulinum toxin A injection: analysis of the UK Medicines & Healthcare Products Regulatory Agency registry and literature review
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Botulinum toxin A (BoNT-A) injection is one of the most frequently undertaken procedures in aesthetic medicine. The Medicines & Healthcare products Regulatory Agency (MHRA) is the government body in the United Kingdom (UK) mandated to ensure that the provision and administration of medicines is safe. We analyzed adverse events of facial cosmetic BoNT-A injections reported to the MHRA and assessed whether the incidence of reported adverse events in this government registry is comparable to published retrospective and prospective studies.
A freedom of information (FOI) request was submitted to the MHRA to obtain recorded complications of BoNT- A. Complications reported to the MHRA between 1991 and 2020 were analyzed. Only cases with BoNT-A where the indication was specified as for facial cosmetics were included in the analysis. Additionally, the literature was reviewed on adverse events of facial cosmetic BoNT- A injections, and a statistical meta-analysis of complication rates was carried out.
A total of 188 adverse events of aesthetic BoNT-A injections were reported to the MHRA. The literature search resulted in 30 studies and a total of 17,352 injection sessions, where the complication rate was 16% (95% CI = 8% to 25%). Frequent adverse events included localized skin reactions such as bruising with an incidence of 5% (95% CI = 3% to 7%), headache in 3% (95% CI = from 1% to 5% ), and facial paresis in 2% (95% CI = 1% to 3%) of injection sessions.
This is the first paper to obtain and evaluate data on adverse events of BoNT-A from the MHRA. An estimate of the likely complication rate of aesthetic BoNT-A in the UK, according to the MHRA database, is significantly lower than the rate recorded from our meta-analysis of the international literature. This suggests that the MHRA may be underestimating the adverse events of aesthetic BoNT-A treatment, which would have implications for patient safety and informed consent. Therefore, legislative changes may be required to ensure more robust reporting of aesthetic BoNT-A in the UK.
Application of Botulinum Toxin at the Yonsei Point for the Treatment of Gummy Smile: A Randomized Controlled Trial
2024, Plastic and Reconstructive Surgery
Botulinium toxin applications in the lower face and neck: A comprehensive review
2024, Journal of Cosmetic Dermatology
Neuromodulator Injection for Gummy Smile
2024, Plastic and Reconstructive Surgery
Use of LetibotulinumtoxinA for Aesthetic Treatment of Asians: A Consensus
2023, Aesthetic Surgery Journal

View all citing articles on Scopus

: Funding sources: None.

: Conflicts of interest: None declared.

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Dermatologic surgeryGummy smile and botulinum toxin: A new approach based on the gingival exposure area

Background

Objective

Methods

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

Dent Clin North Am

Am J Orthod Dentofacial Orthop

J Prosthet Dent

Am J Orthod Dentofacial Orthop

Ann Dermatol Venereol

The aesthetic smile: diagnosis and treatment

Periodontol 2000

Smile aesthetics

SADJ

Cosmetic uses of botulinum A exotoxin

Botulinum toxin in the treatment of glabellar frown lines and other facial wrinkles

Dilution and storage of botulinum toxin

Dermatol Surg

Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology

Dermatol Surg

Gingival smile

Treatment of glabellar frown lines with C. botulinum-A exotoxin

J Dermatol Surg Oncol

Aplicações não-clássicas da toxina botulínica

Botox treatment for expressive facial lines and wrinkles

Curr Opin Otolaryngol Head Neck Surg

Differential diagnosis and treatment of excess gingival display

Pract Periodontics Aesthet Dent

Dermatologic surgery
Gummy smile and botulinum toxin: A new approach based on the gingival exposure area