Evaluation of the botulinum toxin effects in the correction of gummy smile 32 weeks after application

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Carlos Eduardo Alonso Vieira
Wilson Rodrigues de Almeida
Paula Cotrin
Renata Cristina Gobbi de Oliveira
Ricardo Cesar Gobbi de Oliveira
Fabrício Pinelli Valarelli
Julie Watanabe Zamuner
Karina Maria Salvatore de Freitas


Introduction: The use of botulinum toxin type A (BTX-A) to correct gummy smile has become popular in recent years. Objective: To evaluate the effects of BTX-A application in the correction of gummy smile 2 and 32 weeks after application. Methods: The sample comprised 35 patients (30 female, 5 male) at a mean age of 25.51 years (±5.59) with gummy smile due to muscular hyperfunction. In each patient, 2U of botulinum toxin was applied in the levator labii superioris alaeque nasi, 2 mm from the nasolabial fold. Photographs of spontaneous smiles were taken at 3 stages: before, 2 and 32 weeks after BTX application. Measurements of the gingival display were performed with the Radioface Studio 2 Software, and the calibration used the actual size of the right maxillary central incisor. Comparison of the three stages evaluated was performed with repeated measures ANOVA and Tukey tests. Results: Gingival display decreased significantly 2 weeks after BTX-A application and increased after 32 weeks but did not return to the initial value. Conclusion: There was a significant improvement in gummy smile 2 weeks after botulinum toxin application, and a significant relapse in the gingival display after 32 weeks, however not returning to baseline values.


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Vieira, C. E. A., Almeida, W. R. de, Cotrin, P., Oliveira, R. C. G. de, Oliveira, R. C. G. de, Valarelli, F. P., Zamuner, J. W., & Freitas, K. M. S. de. (2022). Evaluation of the botulinum toxin effects in the correction of gummy smile 32 weeks after application. ABCS Health Sciences, 47, e022201. https://doi.org/10.7322/abcshs.2020052.1501
Original Articles


1. Moon JH, Lee E, Lee J-A, Choi TR, Sung Y. The role of narcissism in self-promotion on Instagram. Personal Indiv Differenc. 2016;101:22-5. https://doi.org/10.1016/j.paid.2016.05.042

2. Sharma PK, Sharma P. Dental smile esthetics: the assessment and creation of the ideal smile. Semin Orthodontics. 2012;18(3):193-201. https://doi.org/10.1053/j.sodo.2012.04.004

3. Rohrich RJ. The increasing popularity of cosmetic surgery procedures: a look at statistics in plastic surgery. Plast Reconstr Surg. 2000;106(6):1363-5. https://doi.org/10.1097/00006534-200011000-00023

4. Silva Neto JMA, Silva JLV, Mendonça AJPC, Duarte IKF, Tenório Neto JF. O uso do ácido hialurônico na harmonização facial: Uma revisão de literatura. Rev Eletron Acervo Saúde. 2019;32(Supl):e1269-e. https://doi.org/10.25248/reas.e1269.2019

5. Pascali M, Quarato D, Carinci F. Filling procedures for lip and perioral rejuvenation: A systematic review. Rejuvenation Res. 2018;21(6):553-9. https://doi.org/10.1089/rej.2017.1941

6. Ribeiro F, Steiner D. Quality of life before and after cosmetic procedures on the face: A cross-sectional study in a public service. J Cosmet Dermatol. 2018;17(5):688-92. https://doi.org/10.1111/jocd.12723

7. Maisel A, Waldman A, Furlan K, Weil A, Sacotte K, Lazaroff JM, et al. Self-reported Patient Motivations for Seeking Cosmetic Procedures. JAMA Dermatol. 2018;154(10):1167-74. https://doi.org/10.1001/jamadermatol.2018.2357

8. Ferrandis JFB, Soriano FM, Veja MIR, Ferrandis JJF. Assessment of facial harmony among Caucasian Spaniards 18 to 60 years of age and its relationship with the golden ratio. Eur J Plast Surg. 2018;41:189-206. https://doi.org/10.1007/s00238-017-1348-1

9. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18-28. https://doi.org/10.1111/j.1600-0757.1996.tb00179.x

10. Springer NC, Chang C, Fields HW, Beck FM, Firestone AR, Rosenstiel S, et al. Smile esthetics from the layperson's perspective. Am J Orthod Dentofacial Orthop. 2011;139(1):e91-e101. https://doi.org/10.1016/j.ajodo.2010.06.019

11. Chang CA, Fields Jr HW, Beck FM, Springer NC, Firestone AR, Rosenstiel S, et al. Smile esthetics from patients' perspectives for faces of varying attractiveness. Am J Orthod Dentofacial Orthop. 2011;140(4):e171-80. https://doi.org/10.1016/j.ajodo.2011.03.022

12. Suzuki L, Machado AW, Bittencourt MAV. An evaluation of the influence of gingival display level in the smile esthetics. Dental Press J Orthod. 2011;16(5):37e1-10. https://doi.org/10.1590/S2176-94512011000500005

13. Nomura S, Freitas KMS, Silva PPC, Valarelli FB, Cançado RH et al. Evaluation of the attractiveness of different gingival zeniths in smile esthetics. Dental Press J Orthod. 2018;23:45-47. http://dx.doi.org/10.1590/2177-6709.23.5.047-057.oar

14. Hunt O, Johnston C, Hepper P, Burden D, Stevenson M. The influence of maxillary gingival exposure on dental attractiveness ratings. Eur J Orthod. 2002;24(2):199-204. https://doi.org/10930.1/ejo/24.2.199

15. Silberberg N, Goldstein M, Smidt A. Excessive gingival display-etiology, diagnosis, and treatment modalities. Quintessence Int. 2009;40(10):809-18.

16. Monaco A, Streni O, Marci MC, Marzo G, Gatto R, Giannoni M. Gummy smile: clinical parameters useful for diagnosis and therapeutical approach. J Clin Pediatr Dent. 2004;29(1):19-25. https://doi.org/10.17796/jcpd.29.1.y01l3r4m06q3k2x0

17. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042-51. https://doi.org/10.1016/j.jaad.2010.02.053

18. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, Baik HS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummy smile using botulinum toxin. Angle Orthod. 2009;79(1):70-7. https://doi.org/10.2319/091407-437.1

19. Govindaraju P, Sadand S, Gopal SV, Ramaiah SK, Mathew M, Parashuram SC, et al. Botulinum toxin-An Innovative Treatment Approach in Dental Practice. J Young Pharmacists. 2016;8(1):2-5. https://doi.org/10.5530/jyp.2016.1.2

20. Al-Fouzan AF, Mokeem LS, Al-Saqat RT, Alfalah MA, Alharbi MA, Al-Samary AE. Botulinum Toxin for the treatment of Gummv Smile. J Contemp Dent Pract. 2017;18(6):474-8. https://doi.org/10.5005/jp-journals-10024-2068

21. Pedron IG, Mangano A. Gummy Smile Correction Using Botulinum Toxin With Respective Gingival Surgery. J Dent (Shiraz). 2018;19(3):248-52.

22. Archana MS. Toxin yet not toxic: Botulinum toxin in dentistry. Saudi Dent J. 2016;28(2)63-9. https://doi.org/10.1016/j.sdentj.2015.08.002

23. Niamtu J. Botulinum toxin A: a review of 1,085 oral and maxillofacial patient treatments. J Oral Maxillofac Surg. 2003;61(3):317-24. https://doi.org/10.1053/joms.2003.50069

24. Nasr MW, Jabbour SF, Sidaoui JA, Haber RN, Kechichian EG. Botulinum Toxin for the Treatment of Excessive Gingival Display: a systematic review. Aesthet surg J. 2016;36:82-8. https://doi.org/10.1093/asj/sjv082

25. Hexsel D, Dal’Forno T, Camozzato F, Valente I, Soirefmann M, Silva AF, et al. Effects of different doses of abobotulinumtoxinA for the treatment of anterior gingival smile. Arch Dermatol. 2020. https://doi.org/10.1007/s00403-020-02096-9

26. Chagas TF, Almeida NV, Lisboa CO, Tavares DM, Ferreira P, Mattos CT, et al. Duration of effectiveness of Botulinum toxin type A in excessive gingival display: a systematic review and meta-analysis. Braz Oral Res. 2018;32:e30. https://doi.org/10.1590/1807-3107bor-2018.vol32.0030

27. 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. https://doi.org/10.1016/j.ajodo.2007.04.033

28. Dahlberg G. Statistical methods for medical and biological students. Br Med J. 1940; 2(4158):358-9.

29. Houston W. The analysis of errors in orthodontic measurements. Am J Orthodontics. 1983;83(5):382-90. https://doi.org/10.1016/0002-9416(83)90322-6

30. Midtgard J, Bjork G, Linder-Aronson S. Reproducibility of cephalometric landmarks and errors of measurements of cephalometric cranial distances. Angle Orthodontist. 1974;44(1):56-61. https://doi.org/10.1043/0003-3219(1974)044<0056:ROCLAE>2.0.CO;2

31. Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. 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):1014-9. https://doi.org/10.1097/PRS.0b013e3181e3b6d4

32. Gracco A, Tracey S. Botox and the gummy smile. Prog Orthod. 2010;11(1):76-82. https://doi.org/10.1016/j.pio.2010.04.004

33. Sucupira E, Abramovitz A. A simplified method for smile enhancement: botulinum toxin injection for gummy smile. Plast Reconstr Surg. 2012;130(3):726-8. https://doi.org/10.1097/PRS.0b013e31825dc32f

34. Dastoor SF, Misch CE, Wang HL. Botulinum toxin (Botox) to enhance facial macroesthetics: a literature review. J Oral Implantol. 2007;33(3):164-71. https://doi.org/10.1563/0-835.1

35. Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop. 2005;127(2):214-8. https://doi.org/10.1016/j.ajodo.2004.09.013

36. Prendergast TI, Ong'uti SK, Ortega G, Khoury AL, Onwuka E, Bolorunduro OB, et al. Differential trends in racial preferences for cosmetic surgery procedures. Am Surgeon. 2011;77(8):1081-5.

37. Broer PN, Levine SM, Juran S. Plastic surgery: quo vadis? Current trends and future projections of aesthetic plastic surgical procedures in the United States. Plast Reconstr Surg. 2014;133(3):293e-302e. https://doi.org/10.1097/01.prs.0000438053.21634.84

38. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop. 1992;101(6):519-24. https://doi.org/10.1016/0889-5406(92)70126-U

39. Suber JS, Dinh TP, Prince MD, Smith PD. On a botulinum toxin A for the treatment of a "gummy smile”. Aesthet Surg J. 2014;34(3):432-7. https://doi.org/10.1177/1090820X14527603

40. Indra AS, Biswas PP, Vineet VT, Yeshaswini T. Botox as an adjunct to orthognathic surgery for a case of severe vertical maxillary excess. J Maxillofac Oral Surg. 2011;10(3):266-70. https://doi.org/10.1007/s12663-011-0178-0