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VOLUME 21 , ISSUE 9 ( September, 2020 ) > List of Articles


Botulinum Toxin Type-A for the Treatment of Excessive Gingival Display on Smiling

Jibin Skaria, Nanditha Hegde, Pradeep P George, Tony Michael, Joseph Sebastian

Keywords : Botulinum toxin type-A, Experimental study, Gingival display, Gummy smile

Citation Information : Skaria J, Hegde N, George PP, Michael T, Sebastian J. Botulinum Toxin Type-A for the Treatment of Excessive Gingival Display on Smiling. J Contemp Dent Pract 2020; 21 (9):1018-1021.

DOI: 10.5005/jp-journals-10024-2926

License: CC BY-NC 4.0

Published Online: 20-01-2021

Copyright Statement:  Copyright © 2020; The Author(s).


Aim and objective: To determine the effect of botulinum toxin type-A (BTX-A) in reducing gummy smile. Materials and methods: This was an interventional case series conducted at a tertiary care setting in Mangaluru, Karnataka, India. Twenty patients with the gingival display of >3 mm were selected through convenience sampling technique. 2.5 units of BTX-A were injected under sterile conditions on either side of the face. The effect of the injection on gingival display was measured at the interval of 2, 4, 12, and 24 weeks. At the end of the treatment, the patient was asked to smile and was photographed and was compared to pretreatment photo. Repeated measures analysis of variance (ANOVA) was used to detect the change at each interval and intergroup comparisons were performed using post hoc Bonferroni test. Results: The mean gingival exposure reduction from 4.93 to 3.705 mm at week 2. At the end of 24 weeks, the evaluation showed the mean gingival display of 4.755 mm on administration of 2.5 units on either side. The photographs also showed the change in smile at the end of the treatment. Conclusion: From the study, it was inferred that botulinum toxin was effective in eliminating gummy smile along with noticeable decrease in the nasolabial fold despite for the effect lasting only about 24 weeks. Clinical significance: A nonsurgical method of correction of gummy smiles when compared to surgical intervention is readily accepted by patients. Botulinum toxin type-A for gummy smiles is an effective, conservative, and satisfactory technique.

  1. Delpachitra SN, Sklavos AW, Dastaran M. Clinical uses of botulinum toxin A in smile esthetic modification. Br Dent J 2018;225(6):502–506. DOI: 10.1038/sj.bdj.2018.755.
  2. Sabri R. The eight components of a balanced smile J Clin Orthod 2005;39(3):155–167; quiz 4.
  3. Peck S, Peck L, Kataja M. The gingival smile line Angle Orthod 1992;62(2):91–100; discussion 1-2.
  4. Van der Geld P, Oosterveld P, Van Heck G, et al. Smile attractiveness. self-perception and influence on personality. Angle Orthod 2007;77(5):759–765. DOI: 10.2319/082606-349.
  5. McNamara L, McNamara Jr JA, Ackerman MB, et al. Hard- and soft-tissue contributions to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop 2008;133(4):491–499. DOI: 10.1016/j.ajodo.2006.05.042.
  6. Hunt O, Johnston C, Hepper P, et al. The influence of maxillary gingival exposure on dental attractiveness ratings. Eur J Orthod 2002;24(2):199–204. DOI: 10.1093/ejo/24.2.199.
  7. Alsulaimani FF, Batwa W. Incisors’ proportions in smile esthetics. J Orthod Sci 2013;2(3):109–112. DOI: 10.4103/2278-0203.119685.
  8. Desai S, Upadhyay M, Nanda R. Dynamic smile analysis: changes with age. Am J Orthod Dentofacial Orthop 2009;136(3):310.e1–310.e10. DOI: 10.1016/j.ajodo.2009.01.021; discussion-1.
  9. Geron S, Atalia W. Influence of sex on the perception of oral and smile esthetics with different gingival display and incisal plane inclination. Angle Orthod 2005;75(5):778–784.
  10. Said S, Meshkinpour A, Carruthers A, et al. Botulinum toxin A: its expanding role in dermatology and esthetics. Am J Clin Dermatol 2003;4(9):609–616. DOI: 10.2165/00128071-200304090-00003.
  11. Mazzuco R, Abdalla BMZ. Botulinum toxin for special conditions: gummy smile–advanced points and Indications. Minimally Invasive Aesthetic Procedures. Springer; 2020. pp. 245–248.
  12. Hwang W-S, Hur M-S, Hu K-S, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod 2009;79(1):70–77. DOI: 10.2319/091407- 437.1.
  13. Schendel SA, Eisenfeld J, Bell WH, et al. The long face syndrome: vertical maxillary excess. Am J Orthod 1976;70(4):398–408. DOI: 10.1016/0002-9416(76)90112-3.
  14. Alpiste-Illueca F. Altered passive eruption (APE): a little-known clinical situation. Med Oral Patol Oral Cir Bucal 2011;16(1):e100–e104. DOI: 10.4317/medoral.16.e100.
  15. Mantovani MB, Souza EC, Marson FC, et al. Use of modified lip repositioning technique associated with esthetic crown lengthening for treatment of excessive gingival display: a case report of multiple etiologies. J Indian Soc Periodontol 2016;20(1):82. DOI: 10.4103/0972-124X.164746.
  16. von Arx T, Nakashima MJ, Lozanoff S. The face—A musculoskeletal perspective. A literature review. Swiss Dent J 2018;128(9):678–688.
  17. Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold: the keystone of the smiling mechanism. Plast Reconstr Surg 1989;83(1):1–10. DOI: 10.1097/00006534-198901000-00001.
  18. Pessa JE. Improving the acute nasolabial angle and medial nasolabial fold by levator alae muscle resection. Ann Plast Surg 1992;29(1):23–30. DOI: 10.1097/00000637-199207000-00006.
  19. Rubin LR. The anatomy of a smile: its importance in the treatment of facial paralysis. Plast Reconstr Surg 1974;53(4):384–387. DOI: 10.1097/00006534-197404000-00002.
  20. Sánchez IM, Gaud-Quintana S, Stern J. Modified lip repositioning with esthetic crown lengthening: a combined approach to treating excessive gingival display. Int J Periodontics Restorative Dent 2017;37(1):e130–e134. DOI: 10.11607/prd.3124.
  21. Litton C, Fournier P. Simple surgical correction of the gummy smile. Plast Reconstr Surg 1979;63(3):372–373. DOI: 10.1097/00006534-197903000-00014.
  22. Miskinyar S. A new method for correcting a gummy smile. Plast Reconstr Surg 1983;72(3):397–400. DOI: 10.1097/00006534-198309000-00027.
  23. Ezquerra F, Berrazueta M, Ruiz-Capillas A, et al. New approach to the gummy smile. Plast Reconstr Surg 1999;104(4):1143–1150. DOI: 10.1097/00006534-199909020-00042; discussion 51-2.
  24. Ishida LH, Ishida LC, Ishida J, et al. Myotomy of the levator labii superioris muscle and lip repositioning: a combined approach for the correction of gummy smile. Plast Reconstr Surg 2010;126(3):1014–1019. DOI: 10.1097/PRS.0b013e3181e3b6d4.
  25. Farista S, Yeltiwar R, Kalakonda B, et al. Laser-assisted lip repositioning surgery: novel approach to treat gummy smile. J Indian Soc Periodontol 2017;21(2):164. DOI: 10.4103/jisp.jisp_411_16.
  26. Dolly J, Aoki K. The structure and mode of action of different botulinum toxins. Eur J Neurol 2006;13(Suppl 4):1–9. DOI: 10.1111/j.1468-1331.2006.01648.x.
  27. Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop 2005;127(2):214–218. DOI: 10.1016/j.ajodo.2004.09.013.
  28. Polo M. Botulinum toxin type A (botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop 2008;133(2):195–203. DOI: 10.1016/j.ajodo.2007.04.033.
  29. Sandler P, Alsayer F, Davies S. Botox: a possible new treatment for gummy smile. Virtual J Orthod 2007;20:30–34.
  30. Suber JS, Dinh TP, Prince MD, et al. Onabotulinumtoxin A for thetreatment of a gummy smile. Aesthet Surg J 2014;34(3):432–437. DOI: 10.1177/1090820X14527603.
  31. Aoki R. Pharmacology and immunology of botulinum toxins serotypes. J Neurol 2001;248(Suppl 1):3–10. DOI: 10.1007/PL00007816.
  32. Rappl T, Parvizi D, Friedl H, et al. Onset and duration of effect of incobotulinumtoxin A, onabotulinumtoxin A, and abobotulinumtoxin A in the treatment of glabellar frown lines: a randomized, double-blind study. Clin Cosmet Investig Dermatol 2013;6:211–219. DOI: 10.2147/CCID.S41537.
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