Gummy Smile Correction with Botox

Abstract

Introduction:The psychological stress due to gummy smile could be the key reason to seek orthodontic treatment. Botox has shown to be most effective and minimally invasive technique to correct the gummy smile which is caused due to short upper lip. This case report was done to show its clinical changes in the correction of gummy smile.

Key Word: Gummy smile, Short upper lip, botox.

INTRODUCTION

smiling is the most powerful communication and people with attractive smile radiate warmth that draws others to them instantly.Unattractive smile due to short upper lip and excessive gingival exposure can be self-conscious or even psychologically affected and hence could be the main reason to seek orthodontic intervention. In many instances, orthodontist may fail to correct gummy smile without surgical procedures like lefort 1 osteotomy, crown lengthening and myectomy to muscle resection1.The goal of an orthodontist is to attempt a non-surgical and minimally invasive treatment. A female patient who was treated for a class II division I occlusion about 2 years back now came to the department for treatment of the excessive gingival show she had while smiling. The patient was not willing for any surgical options.At the beginning of the treatment extra-oral smiling photographs were taken. Botox allergic test was done in the patient prior to Botox

injection. Botulinum toxin type A (BTX-A) was diluted by adding 4.0ml of 0.9% normal saline solution without preservatives to 100 U of vacuum - dried botulinum type A neurotoxin complex, according to the manufactures dilution technique. This resulted in a 2.5 U/0.1 ml dose. 1.25U per side was injected in both the right and left levator labii superioris and levator labii superioris alaque nasi muscle (LLS) and an additional 1.25 U per side at the overlap areas of the levator labii superioris and zygomaticus minor muscles (LLS/ZM). Aspiration before BTX-A, injection was done to avoid involuntary deposition of the toxin into the facial arteries (figure1). The patient was clinically evaluated 1 week, 2 weeks and 4 weeks post operatively.

FIGURE1 showing INJECTION SITES

RESULTS

The results of this clinical trial were analysed both by clinical evaluation of gummy smile and with pre and postoperative photographs. The following measurements (called A,B and C) were recorded: A: RP1 to superior border of upper lip vermilion; B: RP1 to inferior border of upper lip vermilion; and C: inferior border of upper lip vermilion border to junction of the gingiva with maxillary right central incisor crown along its own midline (figure 2).The patient began to show improvement approximately 15 days after the injections. After 4 weeks results were definitely observed with a decrease from 8 mm gingival exposure to 2 mm, which was considered as normal gingival display for an adult during smiling.

Figure 2 showing measuring scale

DISCUSSION

The surgical correction of the short upper lip and gummy smile by gingivectomy was an alternative treatment but they are not routinely used to treat hyper functional upper lip elevator muscle. Lefort I osteotomy with superior impaction is most commonly adopted to treat skeletal vertical maxillary excess and the most common limitation of this procedure is the congestion of nasal air way function. Botox injection is an excellent treatment modality in achieving a pleasing smile. A satisfactory result was achieved in all cases and in turn it boosted their self-confidence and social acceptance. Rubin et al3concluded that the levator labii superioris, the zygomaticus minor and superior fibres of buccinators musclesunder the nasolabial fold are responsible for the production of a full smile. Pessa4 indicated that levator labii superioris alaque nasi was responsible for the formation of medial portion of the fold and minimally responsible for the elevation of upper lip and smile formation and he also found that zygomaticus major and minor are responsible for smiling. The ability of BTX-A to produce muscle paralysis by chemodenervation has been utilized to treat our patient with hyper active upper lips.We achieved a reduction of gingival exposure from 8 mm to 2 mm in our patient(image 1 and 2). According to Sarver, a slight amount of gingival exposure is acceptable and that contrary to posed smile, an unposed smile is natural in that it expresses authentic human emotion.

Fig 1: showing the excessive gingival show of the patient.	Fig 2 : showing the difference in the patients smile 2 weeks after botox was injected.

CONCLUSION

It’s the time to broaden the horizon of our profession.The use of Botox is effective, minimally invasive, conservative treatment in patient with short upper lip and gummy smile. However the improvement is temporary and must be repeated every six months to one year.

REFERENCES