management of gummy smile with botulinum toxin … of gummy smile with botulinum toxin type-a: a...

Case Report

Botulinum Toxin for Gummy Smile…Dinker S et al Journal of International Oral Health 2014; 6(1):111-115

Received: 15th September 2013 Accepted: 3rd October 2013 Conflict of Interest: None

Management of gummy smile with Botulinum Toxin Type-A: A case reportSudeeptha Dinker1, A Anitha1, Abhinay Sorake1, Kishore Kumar2

111

Figure 1: Pre treatment photo – Profile view.

Contributors:1Assistant Professor, Department Of Orthodontics & Dento-Facial Orthopedics, A J Institute of Dental Sciences, Mangalore,Karnataka, India; 2Associate Professor, Department OfOrthodontics & Dento-Facial Orthopedics, A J Institute ofDental Sciences, Mangalore, Karnataka, India.Correspondence:Dr. Sudeeptha Dinker. Department Of Orthodontics & Dento-Facial Orthopedics, A J Institute of Dental Sciences, Mangalore,Karnataka, India. Phone: +91 - 9845691661.Email: [email protected] to cite the article:Dinker S, Anitha A, Sorake A, Kumar K. Management of gummysmile with Botulinum Toxin Type-A: A case report. J Int OralHealth 2014;6(1):111-5.Abstract:A 23 year old female patient presented with the chief complaintof gummy smile after previously undergoing Orthodontictreatment. Patient had a straight profile with competent lips andduring posed and unposed smile the patient exhibited excessivegingival display. Since the patient was unwilling to undergoOrthodontic treatment and apprehensive about surgicalprocedures, this problem was addressed by injecting Botulinumtoxin type-A as an alternative treatment approach. Two weekspost treatment; on follow up examination, improved results wereseen without any side effects. As a result, an attractive andconfident smile was perceived by the patient.

Key Words: Botulinum toxin, excessive gingival display, gummysmile

IntroductionSmile plays a pivotal role in conveying the emotion of aperson. In Orthodontics, smile aesthetics is considered tobe an important part of any treatment objective. Gummysmile is a term used to describe excessive display of gingivaltissue in the maxilla upon smiling. This can cause unduepsychological hindrance as the individual with excessivegingival display will be self-conscious and at uneaseregarding the same and thus seek treatment.1 Cosmeticsurgical procedures like the use of Botulinum toxin type-A,dermal fillers, Orthodontic and Orthognathic procedures,dental bleaching and other dental cosmetic substitutes arewidely requested by the adults.2 The advantages of theseprocedures are definitive increase in self esteem. However,some of these procedures are more time consuming than

the others which can further cause impaired psychologicaleffects especially in adults.Botulinum toxin has been widely used for the treatment ofvarious conditions associated with pain and excessivemuscle contraction since the 1970s. Clostridiumbotulinum is an anaerobic bacterium responsible for itsproduction. Among the 8 different serotypes of Botulinumtoxin that exists, Type A (BTX-A) is the most potent andthe most commonly used clinically. Fermentation ofClostridium botulinum leads to a formation of purifiedBTX-A which is a stable, sterile, vacuum-dried powder thatis diluted with saline solution without preservatives.3 Thisfavours the weakening of skeletal muscles by cleaving thesynaptosomal-associated protein SNAP-25, thus inhibitingthe release of acetylcholine from the motor-neuron andenabling the repolarization of the postsynaptic term.4

The purpose of this case report was to show case the use ofBotulinum toxin type – A for the treatment of gummysmile as an alternative treatment approach. The patienthad previously undergone Orthodontic treatment and wasunwilling for Orthognathic surgery. On clinicalexamination, hyperactive upper lip elevator muscles wereseen which was the primary cause for excessive gingival


112

Figure 3a: Pre-treatment – Close-up Posed smile.

Figure 3b: Pre-treatment – Close-up Posed smile.

Figure 2a: Pre-treatment - Posed smile.

Figure 2b: Pre-treatment - Unposed smile.

display. Botulinum toxin type – A has been used previouslyfor the treatment of gummy smile with the same etiology.5,6

This is a case report were the gummy smile was treated bysimilar means.Diagnosis and EtiologyA 23 year old female patient presented to the clinic withthe chief complaint of excessive gingival display. Pre-treatment photographs showed a straight profile withcompetent lips (Figure 1). On smiling, both posed andunposed, clearly indicated that the patient had excessiveshow of gingiva and the patient was very conscience of thesame (Figure 2a, 2b) Close-up photographs were takenwith a metallic scale placed vertically, such that it coincided

with the facial midline during posed and unposed smile.4-5mm of gingival exposure was seen in the incisor regionduring posed smile (Figure 3a). With spontaneous,unposed smile, as detected by the expression of the eyes,

patient showed a gingival display of 8-10mm (Figure 3b).On further examination, hyperactive upper lip elevatormuscles were seen.Treatment ObjectiveThe photographs clearly showed the presence of excessivegingival display with hyperactive upper lip elevatormuscles. As the patient was unwilling to undergoOrthodontic or Orthognathic surgery, the treatmentobjective was to treat the gummy smile with Botulinumtoxin type- A.Treatment ProgressDuring the initial visit, all forms and consents wereexplained to the patient and signed accordingly. Patient’s

medical history was reviewed as well. Before injecting thesolution, patient underwent a standardised photographicsession. Photographs were taken using Nikon D7000camera. The procedure was performed by a Dermatologistwho was also a Botox certified physician.7 Botulinum toxintype-A was diluted according to manufacturer’srecommendations to provide 2.5 units per 0.1ml by adding4.0 ml normal saline solution to 100 units of vacuum-driedClostridium botulinum toxin type-A. Under sterileconditions, 2.5 units were then injected at 2 sites per sidein both overlapping points of the right and left levator labii


113

Figure 4: Musculature of the face: Pinpointing sites for injection.

Figure 5a: Post-treatment - Posed smile. Figure 5b: Post-treatment - Unposed smile.

superioris alaeque nasi, levator labii superioris andzygomaticus minor and levator labii superioris muscle sites(Figure 4).8 The sites for injection were determined to

ensure accurate locations of the muscle. This was carriedout by asking the patient to smile and simultaneouslypalpate the muscles on contraction. No local anaesthesiawas administered and no electromyographic guidance wasused.Treatment ResultsFacial photographs were recorded after two week post

treatment using the same equipment. Extreme effort wasplaced on obtaining standardised, unposed, spontaneoussmiles (Figure 5a, 5b, 5c). Remarkable improvement in the

lip profile was seen and gummy smile reduced to a normalrange.DiscussionThe cause for gummy smiles can be of skeletal,dentoalveolar or soft tissue in origin. The skeletal type iscaused by excessive growth of the maxilla in verticaldirection and is commonly associated with long-face


114

Figure 5c: Post-treatment - Unposed smile.

syndrome.9,10 This condition is often corrected withOrthognathic surgery. Dentoalveolar type could be treatedby using micro implants. However, this form of treatment

will require fixed mechanotherapy at the same time. Forthe patient whose gummy smile was mainly caused due tohyperactive lip muscles, treatment with Botox wasconsidered as an alternative treatment approach. Musclesof facial expression responsible for upper lip elevation andlateral retraction upon smiling are LLSAN, LLS, Zm,zygomaticus major (ZM), risorius, and, to a lesser degree,the depressor septi nasi muscle. All of these musclesinteract with the orbicularis oris muscle in the productionof a smile. The mechanism involved was well described in2 cadaver studies, by Rubin et al11 and another by Pessa.12

Rubin et al concluded that the LLS, the ZM, and thesuperior fibers of the buccinator muscles under thenasolabial fold helps to produce a full smile. Pessaindicated that the LLSAN was responsible for theformation of the medial portion of the fold and minimallyresponsible for the elevation of the upper lip and smileformation. He also found that the ZM and the Zm musclesare primarily responsible for the production of the smile.Botulinum toxin type-A aids to inhibit the release ofacetylcholine by blocking the neuromuscular transmissionand binding to acceptor sites on motor or sympatheticnerve terminals. This inhibition occurs as the neurotoxincleaves SNAP- 25, a protein integral to the successfuldocking and release of acetylcholine from vesicles in nerveendings.13,14 When injected intramuscularly at therapeuticdoses, it produces partial chemical denervation of the

muscle, resulting in localized reduction in muscle activity.Botox has been approved by the Food and DrugAdministration as a safe and effective therapy forblepharospasm, strabismus, cervical dystonia, hemifacialspasm and primary axillary hyperhidrosis. The NationalInstitutes of Health Consensus Conference of 1990 alsoincluded it as a safe and effective therapy for otherunlabelled uses. The use of Botulinum toxin type-A hasbeen extensively described in literature, especially forvarious cosmetic procedures.15 After injecting 1.25UBotulinum toxin on both the side, reduction in excessivegingival display was noticed with maximum effectfollowing 2 weeks. Gingival display gradually increased,but even at the end of 24 weeks, average gingival exposurewas still retained.ConclusionThe Botulinum toxin type-A injection which was used forthe correction of excessive gingival display caused byhyperactive upper lip elevator muscles was seen to behighly effective. The results were extremely satisfactory forboth the patient and the orthodontist. Even though Botoxhas a transitory effect, six months post treatment thegummy smile was still seen to be within the normal range.Hence, depending on the cause and the needs of thepatient, this treatment approach could well be used as analternative procedure for faster and minimally invasivetreatment of gummy smile.References1. Flanary C. The psychology of appearance and the

psychological impact of surgical alteration of the face.In:Bell WH (Editor). Orthognathic and reconstructivesurgery, Volume 1, 1st ed. Philadelphia:WB Saunders;1992. p. 2-21.

2. Gottlieb EL. By the numbers. J Clin Orthod1999;33:278-81.

3. Ananthanarayanan R, Panicker CK. Textbook ofmicrobiology, 7th ed. Hyderabad, India:OrientLongman; 2005.

4. Jaspers GW, Pijpe J, Jansma J. The use of botulinumtoxin type A in cosmetic facial procedures. Int J OralMaxillofac Surg 2011;40:127–33.

5. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, BaikHS, Kim ST, Kim HJ, Lee KJ. Surface anatomy of thelip elevator muscles for the treatment of gummy smileusing botulinum toxin. Angle Orthod 2009;79:70-7.

6. Polo M. Botulinium toxin type A in the treatment ofexcessive gingival display. Am J Orthod DentofacialOrthop 2005;127:214-8.


115

7. Neville JA, Housman TS, Letsinger JA, Fliesher AB Jr,Feldman SR, Williford PM. Increase in proceduresperformed at dermatology office visits from 1995 to2001. Dermatol Surg 2005;31:160-2.

8. Polo M. Botulinum toxin type A (Botox) for theneuromuscular correction of excessive gingival displayon smiling (gummy smile). Am J Orthod DentofacialOrthop 2008;133:195-203.

9. Proffit WR, Fields HW, Sarver DM. Contemporaryorthodontics. St Louis:Mosby Year Book; 2007.

10. Robbins JW. Differential diagnosis and treatment ofexcess gingival display. Pract Periodont Aesthet Dent1999;11:265-72.

11. Rubin LR. The anatomy of a smile: its importance inthe treatment of facial paralysis. Plast Reconstr Surg1974;53:384-7.

12. Brin MF, Hallett M, Jankovic J. Preface. In:Brin MF,Hallet M, Jankovic J, (Editors). Scientific andtherapeutic aspects of botulinum toxin.Philadelphia:Lippincott Williams and Wilkins; 2002.p. v-vi.

13. Benedetto AV. The cosmetic uses of botulinum toxintype A. Int J Dermatol 1999;38:641-55.

14. Binder WJ, Blitzer A, Brin MF. Treatment ofhyperfunctional lines of the face with botulinum toxinA. Dermatol Surg 1998;24:1198-205.

15. Botulinum toxin. Consens Statement 1990;8(8):1-20.

management of gummy smile with botulinum toxin … of gummy smile with botulinum toxin type-a: a...

Documents