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Year : 2014  |  Volume : 3  |  Issue : 1  |  Page : 63-65

Botox injection as a temporary measure for correcting gummy smile

1 Consultants orthodontist, Vikram Perfect, Gokulam, Mysore, India
2 Pedodontist, Vikram Perfect, Gokulam, Mysore, India
3 General dentist, Vikram Perfect, Gokulam, Mysore, India

Date of Web Publication15-Apr-2014

Correspondence Address:
Anil Sargur Ramu
Vikram Perfect, KRS Main Road, Gokulam, Mysore 570 002, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2278-344X.130621

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The exposure of more than 3 mm of the gum during the smile is known as gingival or gummy smile (GS). Botulinum toxin (BT) has been used since 1989 for cosmetic reasons to treat frown lines and since, then its use has been tried for various cosmetic procedures, the effects of which can last from 6 weeks to 8 months. BT has been tried as an initial and temporary option for treatment of GS cases due to the ease and safety of the applications. We hereby report a case of GS induced by orthodontic treatment for proclination correction by extracting upper and lower first premolars treated effectively by local administration of BT. Though the treatment effects lasts for 6 months to 1 year the cosmetic benefits are worth the treatment procedure.

Keywords: Botulinum toxin type A, gingival display, gummy smile

How to cite this article:
Ramu AS, Shivappa V, Siraj Z. Botox injection as a temporary measure for correcting gummy smile. Int J Health Allied Sci 2014;3:63-5

How to cite this URL:
Ramu AS, Shivappa V, Siraj Z. Botox injection as a temporary measure for correcting gummy smile. Int J Health Allied Sci [serial online] 2014 [cited 2023 Oct 1];3:63-5. Available from: https://www.ijhas.in/text.asp?2014/3/1/63/130621

  Introduction Top

Among all the human facial expressions, the smile is probably the most pleasing and the most complex in terms of meaning. Although, it has long been the motive for artistic and philosophical debates, the smile, from an anatomic and physiologic standpoint, is the result of the exposure of the teeth and gums during the contraction of the muscle groups in the middle and lower thirds of the face. The smile itself and the esthetics of the smile are influenced by 3 components: Teeth, gums and lips. [1],[2] The upper lip should symmetrically expose up to 3 mm of the gum and the gum line must follow the contour of the upper lip. [1] The exposure of more than 3 mm of the gum during the smile is known as gingival or gummy smile (GS). Various causes have been described for GS, including lip length, clinical crown length and mainly altered passive eruption or vertical maxillary excess. In contrast, the behavior of perioral muscles critically influences the structure of the smile. For some patients, GS represents an esthetic disorder and therefore various correction methods are proposed, including gingivoplasty, orthodontic treatment, orthognathic surgery and bone resection. [3] Botulinum toxin (BT) can be used as an initial and temporary option for treatment of such cases because of the ease and safety of the applications, the use of small affordable doses and the fast onset of action, low risk and reversible effect. [3] Herewith, we are reporting a case of iatrogenic GS induced due to uncontrolled tipping of the upper anterior teeth during the retraction of upper anterior segment which was effectively treated with BT [Figure 1].

  Case Report Top

The case report is about a 21-year-old female patient who had presented to a tertiary care center with the complaints of GS following orthodontic treatment for Class II malocclusion of teeth by extraction of all four first premolars 2 years back. On examination, more than 3 mm of gum was exposed in the area between the canine, involving the action of the levator labii superioris alaeque nasi (LLSAN) muscles [Figure 2]. The exaggeration of GS was due to uncontrolled tipping of maxillary incisors. According to Goldstein's classification, the case was diagnosed as anterior GS.
Figure 1: Post orthodontic treatment of lateral cephalogram showing excessive tipping of the upper incisors

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Figure 2: Gummy smile before botulinum toxin type A treatment

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After the thorough evaluation, patient was referred to the dermatologist for BT injection. The brand of BT used was Allergan BT Type A, made in Ireland, 500 I.U./vial, diluted in 2 ml of 0.9% sodium chloride solution immediately before injections, following the recommended guidelines on dilution and storage. Before the injections, the patient received topical anesthesia with a cream containing lidocaine and prilocaine. The patient received injections in accordance with the conventional techniques. 1.5 I.U on each side of the nasolabial fold, 1 cm lateral and below the nasal ala to relax the LLSAN muscle. Following the administration of BT, patient completely recovered [Figure 3].
Figure 3: Gummy smile after botulinum toxin type A treatment

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  Discussion Top

Goldstein13 classified the smile line (consisting of the lower edge of the upper lip during the smile) according to the degree of exposure of the teeth and gums into 3 types: High, medium, or low. The first is characterized by the exposure of more than 3 mm of gum during the smile, which clinically translates as GS. [3] Tjan and Miller reported gender differences in the smile line. In men, the authors report that the low smile line is predominant (2.5:1), whereas high smile lines are predominant in women (2:1). Perhaps, for this reason, GS is a more common occurrence in women. Since, the discovery of the cosmetic use of BT it has been rapidly incorporated into the arsenal of effective treatments for the improvement of unaesthetic facial conditions. Since more than two decades, BT has been used for cosmetic purposes, several new indications have been found and application techniques are being constantly refined. [4] 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 correction of changes caused by muscle contraction in the middle and lower thirds of the face and neck, including GS. [5],[6] Various forms of BT viz. Onabotulinumtoxin A and abobotulinumtoxin A were used by various authors in treating the cases of GS that have found to be equally effective. [3] Mario polo observed that all 5 patients of GS treated with BT began to show improvement approximately 10 days after the injections. After 14 days, results were definitely observed. The pre- and post-operative measurements were recorded and compared. [7]

  Conclusion Top

BT can be used as an initial treatment for GS as remedial when the cause of GS is exclusively muscular or as an adjuvant when there is an association of causes and indication of additional treatments such as lip augmentation or orthodontic devices.

  References Top

1.Garber DA, Salama MA. The aesthetic smile: Diagnosis and treatment. Periodontol 2000 1996;11:18-28.  Back to cited text no. 1
2.Gill DS, Naini FB, Tredwin CJ. Smile aesthetics. SADJ 2008;63:270, 272-5.  Back to cited text no. 2
3.Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: A new approach based on the gingival exposure area. J Am Acad Dermatol 2010;63:1042-51.  Back to cited text no. 3
4.Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51:24-8.  Back to cited text no. 4
5.Foster JA, Barnhorst D, Papay F, Oh PM, Wulc AE. The use of botulinum A toxin to ameliorate facial kinetic frown lines. Ophthalmology 1996;103:618-22.  Back to cited text no. 5
6.Borodic G. Immunologic resistance after repeated botulinum toxin type a injections for facial rhytides. Ophthal Plast Reconstr Surg 2006;22:239-40.  Back to cited text no. 6
7.Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop 2005;127:214-8.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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