Republic of Iraq
Ministry of Higher Education
And scientific research
Asoul Aldeen unviersity collage
Deparment of dentistry
Filler and botox in gummy smile
The project is submitted to the Faculty of Dentistry at
the Faculty of Fundamentals of Asoul Aldin
University, in par-tial implementation of the Bachelor
of Dentistry program
By:
Mohammed khder abbas
Tamam Ali Mutab
Hawraa waleed AbdulWahid
Maryam kassim hashim
Supervisor
Msc Dr. Tariq Nassif
1444‫ــھ‬
2023 ‫م‬
Dedication
This thesis is dedicated to the people who have supported me
throughout my education.
Thanks for making me see this adventure through to the end.
I dedicate this project to my family who told me to always keep their
head up
Acknowledgment
First of all we thank God for the most mercy for enabling us to
present this project in the best form that we wanted to be, we
thank our faculty and doctors that provided us with all the
knowledge. Most of all we are all thankful for our families for
their endless love, assistance, support and encouragement. And
for our friends for their understanding and support for us to
complete this project.
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Stages in the genesis of a full smile
Different muscles involved during
a maximum smile.
Smile type.
Classification of altered passive
eruption (APE)¹4.
Smile dynamic shows how the gingival
smile becomes evident.
Intra-oral pictures show health of soft
and hard tissue.
Incisions with a 15 C blade.
After removing the collar of
'excessive' gingiva.
Once even the left side of the mouth streated,
the natural enamel wonderfully reflects light.
A full thickness flap is elevated to
confirm the x-ray diagnosis.
This problem requires bone resective
surgery in order to remove the buccal excess
bone, and to create a biologic width for soft
tissue attachment.
Once resorbable sutures are placed.
The new smile is clearly a big improvement.
One year follow-up shows perfect
stability and adaptation.
The gummy smile long gone and a new
bright smile has now taken its place.
16
17
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19
20
21
22
23
24
25
26
27
28
29
30
The history of this case showing the dramatic
improvement with a very simple surgical
procedure.
Vertical maxillary excess.
Bimaxillary protrusion.
Gingival hyperplasia in acute
leukaemia patient.
Clinical appearance of drug- influenced
gingival enlargement at the anterior dentition.
Gingival changes in a patient on
oral contraceptives.
Overgrown gums during braces
and orthodontic treatment.
Preoperative smile line showing short
upper lip and excessive display of gums
The lip repositioning surgery as originally
described in the dental literature.
Non surgical procedure Mercado-rosso
gummy smile classification
- Overview of the therapeutic strategies
according to the Mercado-Rosso gummy
smile classification system
Treatment strategy of gummy smile type
1 Treatment strategy of gummy smile
type 2 Patient with gummy smile type 3
Bage number Chapter name
1
Introduction.
3
Anatomy.
6
Classification of gummy smile.
7
Diagnosis of gummy smile (GM).
8
Etiologies of gummy smile .
14
Bony maxillary excess .
17
Conditions causing gingival
enlargement.
21
Treatment of gummy smile.
37
Mercado-Ross classification of gummy
smile.
Filler and Botox in
gummy smile
Abstract
From a periodontal point of view, various factors contribute to facial aesthetics. In
the recent past, studies have revealed that excessive gingival display is a factor
that influ-ences an individual’ smile line. Some literature exists to support that
more than excessive gingival display of more than 3mm is considered unaesthetic
and termed a ‘gummy smile’ (GS).
5
The prevalence of gummy smile’ has been 10% and to be more common in females.
Gingi-val hyperplasia altered passive eruption, vertical maxillary excess, and upperlip hyper-mobility can all result in excessive gingival display when a patient smile.
To select the correct treatment protocol, accurate diagnosis is essential. Various
tech-niques have used to treat gummy smile which includes surgical and nonsurgical methods. Recently nonsurgical method using Botulinum toxin gained
polarity considering that the method is minimally invasive.
6
Introduction
A patient’s smile can express a sense of joy, success,
sensuality, af-fection, courtesy, and show confidence and
kindness. Smile is more than a form of communication; it i.
kind of socialization and at-traction.
Dentistry is undoubtedly the health profession that deals most with
smile enhancements. However, dental professionals often overlook
key considerations precisely in their planning regarding smile
patterns.As suggested, part of the smile esthetics is subjec-tive, but
most is objective evaluation. The media offer a stereo-typed picture
of the smile that leads to smile standardization and consequently, an
increased patients’ demand for cosmetic dentistry. Differently from
what some dentists consider, smile harmony is de-termined not only
by the shape, position and color of teeth, but also by the gingival
tissue. The gingival margin should be as smooth as dental criteria
alone. Today, both patients and dentists should be more aware of the
impact of gingival upon the beauty of the person’s
smile.Periodontium visibility depends on the position of the smile
line, which is defined as the ratio between the upper lip and visibility
of the gingival tissue and teeth. Smile level is an imaginary line that
follows the lower margin of the upper lip and usually has a convex
appearance. Excessive exposure of the peri-odontium characterizes
the so-called gingival or gummy smile.It should be emphasized that
the current aesthetic standards estab-lish a dimorphism concept
influenced by age and gender. Thus, a healthy and continuous
gingival margin display of around 3 mm during natural smile is
desirable for women; for men, only the an-terior teeth display is
expected, without the continuous band of gingiva. Age influence is
due to the loss of muscle tone, with a con-
7
sequent lower visibility of the upper teeth and a tendency
to in-crease lower teeth display.[1,2]
The first step in establishing a correct diagnosis is to properly classify the gingival level, taking into consideration variables such as
gender, age and periodontal health. The literature, although, abundant in this respect, is not clear and uniform; the authors present
different ways of classifying the same thing.[3-5] once the abnormality in the smile level is determined, the establishment of the
gummy smile etiology is essential. Generally, it is multifactorial
interacting and is related to excessive vertical growth of maxilla,
reduced length of the upper lip, excessive contraction of the upper lip
and disproportionate crown length and width of anterior teeth,
usually, associated with excessive gingival display, and hyperpla-sia
or passive eruption.[6-8] upper teeth extrusion, associated with deep
bite, can also be related to the problem.[9,10]
It is precisely the etiology of gummy smile associated with its
classification that will establish a correct diagnosis, upon which
all kinds of treatment will be based. In other words, the various
types of treatment and their multidisciplinary nature are
respected, having, however, just a single one diagnosis. Thus,
this literature review seeks to establish the diagnosis, etiology
and treatment al-ternatives available to correct gummy smile.
Review
8
The smile is a common human expression that reflects different
feelings[11] . The smile is an important aesthetic component of
the face and significantly impact on the perception of beauty
and personality that the others have about us. Additionally,
asymmetries in our face or expressions, as well as face proportions, also play an important role in the perception of beauty .
[12,13] Gingival display during smile, that is, the exposure of the
gingival tissues surrounding the maxillary anterior teeth when
smiling, is common. Studies report that 14% to 70% of females
[14-19] and 7% to 38% of males present with gingival display,
[14-19] that is, they have a high smile. Females are, on average,
twice as likely as males to have a high smile, regard-less of age
or ethnic origin. [14-21] . Intrinsically, gingival dis-play is an
acceptable component of a pleasing smile; however, smile
attractiveness typically decreases when gingival display
exceeds 2 to 3 mm, which is termed excessive gingival display.
[22-26]
Excessive gingival display, often referred to as gummy smile, is
a condition resulting from diverse causes and is often multifac-
torial
Anatomy
Muscles responsible for upper lip movement during
smile are:
9
1. Levator labii superioris(LLS)
2. Levator labii superioris alaeque nasii(LLSAN)
3. Zygomaticus major
4. Zygomaticus minor
5. Depressor septii
Mimetic facial muscles (MFM) have various features that differentiate them from other skeletal muscles. The first one is
the lack of any tendinous or aponeurotic intermediaries [27].
MFM are, indeed, directly attached at each end and generally
originate from underlying bone surfaces and insert to the skin
of the face or intermingle with other facial muscles . [28]
Upper lip muscles include the zygomaticus major and minor,
the levator labii superioris (LLS), the levator labii superioris
alaeque nasi (LLSAN), as well as the levator anguli oris (LAO)
[29,30] . Different levator muscles pull the upper lip and the
corner of the mouth upwards, while the zygomatic muscles
have a diagonal action [29,30 ] . The lip muscles can be
divided in dilator and constrictor muscles [31] . Dilator
muscles are, in turn, distributed into two layers, namely superficial and deep. The superficial layer contains seven muscles: LLSAN, LLS, zygomaticus major and minor, risorius,
depressor anguli oris (DAO), and platysma[31] . The characteristics of the smile are determined by the interaction of the
static and dynamic relationships between the dento-skeletal
and soft tissue components of the face. The smile is formed in
two stages (Fig. 1).
10
During the first stage, the contraction of the levator
muscles raises the upper lip to the nasolabial fold. The
second stage involved further raising superiorly of the lip
and the fold by three muscle groups: (1) the levator labii
superior muscles of the upper lip, originating at the
infraorbital region; (2) the zygomaticus major muscles;
and (3) superior fibers of the buccinator (Fig. 2)
Although showing a certain amount of gum (1 mm–2 mm)
during a normal mile is aesthetically acceptable and in many
cases imparts a youthful appearance [ 33-35] , excessive gin-
11
gival visualization during the smile has been an aesthetic
problem for many patients, which can defi- nitely affect their
psychosocial behavior [36] . Perception of excessive gingival
display is also subject to cultural and ethnic preferences. The
quantity of gingival showed that is considered unaesthetic, or
excessive, is highly subjective, and varies between males and
females [37, 38 ] ,and between professionals and laypeo-ple
[39,40] . For example, in some European countries gingi-val
display of up to 4 mm or more is acceptable, while expo-sure
greater than 2–3 mm is considered unsightly in the USA
[41]. Gummy smile has been defined as a nonpathological
condition causing esthetic disharmony in which more
than 3 mm of gingival tissue is exposed when smiling [33,
42] . The GS constitutes a prevalent condition that occurs
in 10.5%– 29% [42, 43] of young adults, with the
prevalence being high-er in women . [33]
Classification of gummy smile
The smile can be classified according to different parameters (Table 1). For example, depending on the lips raising
direction and the muscle group involved in the smile, it is
classified into three categories: The cuspid smile, the
complex smile, and the commissure smile or Mona Lisa smile
12
Figure 3:
[32, 44, 45]
Diagnosis of gummy smile (GM) :
Correct diagnosis of GM is done by identifying the etiology with the
help of medical and dental history that provide patient age and
eruption stage of dentition along with contributing factors for GM.
Followed by periodontal examination to measure width of attached
gingiva, probing pocket depth and clinical attachment loss to rule
out any pathologic and nonpathological changes in the architecture
of the periodontium. Later analysis of face done to evaluate vertical
maxillary excess (VME) by cephalometric analysis. Lip analysis
done both in static and dynamic posture to assess lip length, hypermobility, or both. Dentialveolar analysis is done to measure the
interlabial gap by analyzing 3D position of the incisors during rest
position. 0-4mm is considered normal interlabial gap.[46,47]
Clinical Diagnosis
The clinical examination should include the determination of
the following: clinical crown length (gingival margin to incisal
edge), anatomic crown length (CEJ to incisal edge), width of
keratinized gingiva (mucogingival junction to free gingival
margin), location of alveolar crest, tooth position, and frenum
13
involvement. Periapical radiographs of the teeth involved in
the treatment are necessary.
Etiologies of gummy smile :
Many studies have stated the main causes of excessive gingival display, presenting the most important factors which may
lead to having a Gummy Smile. The study of Roe et al., [48],
described that lip length and the upper lip mobility rate are the
main contributing factors. The previous research of Peck et
al.,[49] stated that the exposure of teeth and gingiva de-pends
on the integrated effects of a number of variables (in-creased
muscle capacity, vertical maxillary excess, greater in-terlabial
gap at resting position, and the amount of overjet and
overbite). Pausch et al.,[ 50] mentioned that abnormal gingival
and maxillary anterior teeth display may take place due to
numerous anatomic or functional factors, either hered-itary or
inborn. A narrow upper lip, an irregular eruption of teeth,
excessive protuberance or vertical maxillary growth, and
hypermobility of the maxillary lip and elevator muscle are
common reasons for a Gummy Smile.
In fact, several contributing factors are affecting individuals
to have a Gummy Smile. Sometimes one of them is presented, although in some cases more than only one cause can
be seen. Correct diagnosis of the reason leads to a proper
treat-ment plan. The most common and discussed factors
associat-ed with Gummy Smile are:
Altered passive eruption :
14
Also known as impaired passive eruption, [ 51] is defined as
a condition in which the relationship between teeth, alveolar
bone in the maxilla, and the soft tissues displays an
excessive gingiva. This, in turn, reveals the clinical
characteristic of Gummy Smile[52]. In other words, altered
passive eruption (APE) is characterized by excessive
gingival exposure in rela-tion to the crowns of the maxillary
teeth.[53] in this case, the gingiva fails to migrate in the
apical direction during the eruption of teeth, thus, it remains
in a coronal position in re-lation with the cementoenamel
junction (CEJ), which results in having an unacceptable
gingival exposure and unfavor-able small size of the teeth
when smiling . [54] Miskinyar et al.[55] ,found that the
prevalence of this condition is about 12% of the population.
Altered passive eruption was first identified by the study of
Coslet et al.[56] ,and according to Rossi et al.,[52] it was
classified into two types and two sub-types (Fig 1),
1. Type I : the vertical length of keratinized gingiva is greater
than normal, the mucogingival junction (MGJ) is located in
an apical position to the level of the cementoenamel
junction (CEJ), and clinical crowns appear shorter.
2. TypeII:theverticaldimensionofthekeratinized gingiva is
normal, the mucogingival junction is positioned at the
lev-el of the CEJ.
2.1 Subtype A : the measurement between the maxillary
alve-olar crest and the CEJ is around 1.5 mm, and in this
case a regular attachment can be found.
2.2 Subtype B : the level of maxillary alveolar crest is at the
level of the CEJ, or occlusal to the CEJ in some cases.
15
‫تسمية توضيحية‬
‫‪16‬‬
17
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Bony maxillary excess :
This includes vertical maxillary excess and bimaxillary
pro-trusion .
A.
Vertical maxillary excess :
Wolford et al., [ 57] defined Maxillary vertical hyperplasia or
vertical maxillary excess as an excessive vertical growth of
the maxilla which may or may not lead to an anterior open
bite. In his study Robbins [ 58] explained that to make the
correct diagnosis, the face must be divided into three equal
thirds or parts for the critical evaluation of the height of the
face. Vertical maxillary excess is noticed when the length of
the lower third of the face is more than the other two thirds,
causing an excessive gingival display. [ 59] In the analysis of
the face, vertical maxillary excess has the following features:
longer lower third of the face, in relation with the upper and
middle thirds, a greater display of maxillary incisors at rest,
an incompetent lip, inclination towards class II malocclusion
with or without open bite, and a noticeable Gummy Smile. The
nose is longer as well, the alar bases are small and the
zygoma appears to be generally flat. The lower third of the
face is long, leading to a retrognathic shape of the jaw
[60] .Furthermore, the incisal edge of the upper anterior teeth
might be covered by the lower lip because of the extravagant
downward growth of the maxilla . [61] Peck et al., [62] and
Mackley [63] found that a Gummy Smile is highly related to
anterior vertical maxillary excess (about 2-3 mm). Moreover,
Ezquerra and Berrazueta [64] discuss that excessive maxilla
19
associated with the protrusion of anterior alveolar bone
con-sequently produce a Gummy Smile. Whilst Wu et al.,
[65] in their study also stated that anterior maxillary
height (upper incisor to the palatal plane) was
considerably more in both male (+1.03 mm) and female
(+2.13 mm) groups who have Gummy Smile.
B. Bimaxillary protrusion :
Bimaxillary protrusion is a frequently diagnosed deformity in
African Americans [66] ,and Asian populations as well. This
deformity is described regarding the protrusive and buccally
positioned maxillary and mandibular incisors, as well as the
enlarged prostration of the lips. It can be found with an incompetent lip, excessive gingival display, mentalis strain with
an anterior open bite. Bimaxillary protrusion refers to an abnormally protruded maxillary and mandibular dentoalveolus.
Generally, this presents with malocclusion and dentoalveolar
flaring of both the maxillary and mandibular anterior teeth,
which cause the lips to be protruded, thus, producing an additional convexity of the facial profile. Bimaxillary protrusion is
mainly accompanied by several degrees of lip deficiency (de-
20
fined as more than 4 mm of lip detachment at the rest state).
The tendency of the anteroposterior correlation is to be a class
II
malocclu-
sion
with a de-
ficient
mandible,
al-
though it
may
also range
from
class
severe
II to class
III. [67] The etiology behind bimaxillary protrusion is associated with various reasons between genetics and environment,
such as mouth breathing, lip biting habit and large size of the
tongue. [68] Keating et al., [69] discovered that in Caucasians
with bimaxillary protrusion, it is likely to notice a posterior
cranial base which is shorter than normal, a prognathic maxilla with vertical excess, mild class II skeletal occlusion, and a
prostrate profile.
Conditions causing gingival enlargement :
Gingival enlargement might be the outcome of bacterial
plaque-enhanced chronic inflammation and medications.[54]
21
Narwal et al., [70] showed in their case report an abnormal
unilateral palatal soft tissue enlargement in a 61-year-old hypertensive female using amlodipine, which is a safe antihypertensive drug. Ritchhart et al., [71] stated a process behind
uncontrolled cell proliferation in drug- induced gingival
overgrowth which is the suppression of apoptotic pathways,
with the following effect on the normal gingival formation by
cell turnover. Hormonal differences which take place in
pregnancy and puberty, in addition to the use of oral contraceptives have been associated with gingival overgrowth.[54]
other effects such as age, demographic and pharmacokinetic
changes, genetic predisposition, oral hygiene condition, as
well as molecular and cellular variables may impact the
mechanism of gingival enlargement. [71, ,72] Orthodontic
treatment using orthodontic appliances can also participate in
the presence of gingival enlargement. [73] In the case of
leukemia, leukemic cells might infiltrate to the gingiva,[74] and
this will cause some manifestations to be present such as
gingival enlargement and bleeding.[75]
22
Short upper lip :
The upper lip length is defined as the length from the base of
the nose (subnasale point) to the inferior part of the upper lip
(upper lip stomion point),[48] which is normally around 23
mm in males and 20 mm in females[76] . If an individual with
excessive gingival display has a short upper lip as well, the
esthetic compromise will be affected.[58] The diagnosis of an
excessive gingival display can be done regarding the clinical
measurement of the upper lip length with an exces-sive
amount of tooth display at rest.[54] Conversely, Roe et al.,
[48] found in their study that in maximum smile, there is no
notable difference in the gingival display between an in-
23
dividual with a short or normal upper lip, and they conclud-ed
that the association of some factors such as higher muscle
capacity, vertical maxillary excess, excessive interlabial gap at
rest, and the amount of overjet and overbite have a greater effect on the gingival display than the upper lip length itself.
Moreover, Sarver et al., [77] explained that what is crucial is
the correspondence between the upper lip length, the maxilliary incisors, and the commissure of the mouth. In other
words, the lip length should be almost equal to the commis-
sure of the mouth.
Hypermobility of the upper lip :
In the case of normal face height, gingival levels, lip length
and length of central incisors in a patient who has an excessive gingival display, the possible etiology is hypermobility of
the maxillary upper lip.[58] Upper lip mobility was ex-plained
as the volume of lip movement that exists when an individual
smiles. This was measured by deducting the in-cisal shown at
rest from the dentogingival display during a full smile. [48]
Hypermobility of the upper lip is associated with a hyper
function of the lip elevator muscles and basical-ly leads to
excessive gingival display.[ 64] Peck and Peck [ 78] reported
an average lip movement of 5.2 mm (23% decrease) from a
measured lip length of 22.3 mm during a full smile.
Furthermore, in a study evaluating spontaneous smiles,
24
Tarantili et al., [ 79] identified a 28% decrease in the initial
upper lip length, while Roe et al., [48] concluded the overall
means of lip mobility for females with normal lip length,
females with short lip length, males with normal lip length
and males with short lip length were 5.8 ± 1.7 mm, 5.0 ± 1.3
mm, 6.7 ± 1.5 mm, and 5.7 ± 1.1 mm, respectively. Moreover,
Sabri et al., [76] stated that in smiling, the upper lip is
elevat-ed by about 80% of its original length. Bhola et al.[54]
as well as Robbins[48] stated that the upper lip is generally
elevated around 6-8 mm from the rest position to the
position reached when a full smile takes place.
Treatment of gummy smile :
Excessive gingival display can be managed by a variety of procedures. These procedures include non- surgical and surgical
methods. The underlying cause of excessive gingival display or
Gummy Smile has the main effect on the type of procedure that
will be performed. [80] Non-surgical procedures may include
Botulinum toxin type A injection as well as orthodontics, While
surgical procedures might include lip repositioning or
orthognathic surgery following orthodontics.
A.Surgical procedures :
In the case of altered passive eruption :
a higher amount will exist, and the treatment of choice is
normally gingivectomy following by aesthetic crown lengthening to attain the desired dimension and morphology of
25
teeth. However, when the diagnosis shows bone levels close
to the CEJ, a gingival flap with ostectomy is performed, or
what is also known as an apically positioned flap. [81] Orthodontic eruption or intrusion can also be done when hav-ing
gingival asymmetry on one or multiple anterior teeth[81] .
In the case of vertical maxillary excess :
the only treatment option to consider is orthognathic surgery.
[82] This is applied to impact the maxilla considering the
amount of gingival exposure diagnosed. Maxillary
impaction allows correction of the Gummy Smile, long
face syndrome, specific types of open bite from a skeletal
origin and labial sealing. [83] The Le Fort I osteotomy of
the maxilla allows re-duction of bone between the nasal
floor and apices of maxil-lary teeth which permits
superior repositioning (impaction) of the maxilla. [59]
In the case of the bimaxillary protrusion :
the treatment option may be composed of first premolar extractions followed by the osteotomy through the extraction
sites to mobilize the anterior segment of the maxilla. The
aim is to setback the segment in addition to lessening the
labial flaring of the incisors. Maxillary setback alone can
sometimes provide a substitute for the treatment of
anterioposterior maxillary excess without any need for tooth
extraction or segmental osteotomy in these cases:
26
(1) it is contraindicated to perform extractions in an
ortho-dontic diagnosis (no dental crowning, adequate
curve of Spee, etc.)
(2) the proclination of maxillary incisors can be
adjusted to an acceptable position with a Le Fort I
osteotomy in addition to clockwise rotation. [67]
In the case of excessive gingival display resulted from
short upper lip and/or hypermobility of the upper lip :
a surgical procedure known as lip repositioning surgery is
preferred for a minimally invasive surgery. It is composed
of an oval mucosal excision followed by coronally advanced flap. This procedure is done to reduce the hyperactivity of the elevator muscles and reform the depth of the
vestibule[84] . It was first described by Rubinstein and
Kostianovsky [ 85] and the aim was the treatment of excessive gingival display associated with hypermobility of
the lip, and was then modified by Litton and Fournier[86] to
include also the treatment of Gummy Smile caused by
short upper lip, by separating the muscles from the underlying bony structures to place the upper lip in a coronal
position. This surgical procedure was accompanied with
no complications, although there were some incidences of
relapse, [87] consequently, some attempts were done to
improve it by Miskinyar. [88] Recently, Bhola et al.,[ 54]
described a technique similar to the one which was described by the article of Rubinstein and Kostianovsky under the name of Lip Stabilization Technique (LipStaT).
27
The only obvious difference between the two techniques
is that in LipStaT, a vertical incision is done posteriorly to
connect the inferior incision (at the mucogingival
junction) and the superior incision (into the vestibule).
The ratio of this incision is the height being double of
gingival expo-sure during a full smile. While in Rubinstein
and Kos-tianovsky technique, the two incisions were
approximated till they meet posteriorly.
In the case of the presence of external
factors causing gingival overgrowth :
the treatment plan should be focused on the exact cause of
the enlarged gingiva. Meticulous history taking, in addition to
an excisional/incisional biopsy and/ or hematologic/histo-logic
inspection might be performed generally to make the correct
diagnosis of the uncommon conditions of gingival enlargement. Plaque control is an important aspect of treatment
28
in all the patients. Some of these cases may resolve when
the external element that is inducing the gingival
enlargement is adjusted or suspended, For example,
gingival overgrowth during pregnancy and puberty might
need the elimination of all local irritants followed by surgical
treatment for the re-moval of any fibrotic residuals.[89]
B. Non surgical procedures :
the injection of Botulinum toxin type A which has been suggested for treatment of hypermobility of the upper lip, but
this may only provide temporary advantages. [90]
Another way to fix a gummy smile is by using dermal
fillers or lip fillers. By injecting your lips with a dermal
filler, we can plump up your upper lips and reduce the
amount of gum shown.
29
Botox :
Botox is the trade name for the neurotoxin protein botulinum
toxin type A produced by fermentation of anaerobic bacterium
clostridium botulinum. Type A is one of the seven distinct botulinum toxins produced by different strains of the bacterium.
It is a stable, sterile, vacuum-dried powder that is diluted with
saline solution without preservatives for it to be injected.
30
The total "dose" of Botox in each vial is always 100 units but
different amounts of saline solution can be used with each vial
depending on the intended use
Each vial of BOTOX contains :
1. 100 Units (U) of Clostridium botulinum type A
neurotoxin complex,
2. 0.5 milligrams of Albumin Human,
3. And 0.9 milligrams of sodium chloride in a sterile,
vacuum-dried form without a preservative.
A brief history of botox :
Over the last two decades, BOTOX has been approved by the
Food and Drug Administration (FDA) for therapeutic treatments of eye muscle problems (in1989), neck problems (in
2000), and excessive sweating (in 2004). At present, it is being
investigated for treating other medical conditions. In 2002, the
FDA approved Allergen’s BOTOX Cosmetic for the pur-pose
of temporarily erasing facial lines[91,92&93 ] .
Mechanism of Action :
BOTOX decreases muscle activity by blocking overactive
nerve impulses that trigger excessive muscle
contractions or glandular activity .
Phase I. Nerve-Muscle Communication
is blocked :
BOTOX blocks the transmission of overactive nerve impulses
to the targeted muscle by selectively preventing the release of
the neurotransmitter acetylcholine (ACh) at the neuromuscu-
31
lar junction, temporarily preventing muscle contraction. This
is primarily a local effect. BOTOX may also prevent the release of pain-stimulating neuropeptides in peripheral nerves.
A) Binding :
The heavy chain portion of the active ingredient in BOTOX
binds to the cell membrane of the motor nerve via an unidentified high-affinity “acceptor” molecule. This high-affinity
binding action allows for efficient uptake of BOTOX® by the
motor nerve and facilitates selective, targeted treatment at the
injection site.
B) Internalizing :
After binding, the BOTOX protein molecule passes
through the cell membrane of the motor nerve and into
its cytoplasm via a process called endocytosis. It is here
that the enzymatic component (light chain) of the BOTOX
protein molecule is activated.
32
C) Blocking :
Inside the motor nerve, the light chain of the BOTOX protein
molecule cleaves apart a protein (called SNAP25) that enables
vesicles which store the neurotransmitter acetylcholine to attach to the cell membrane. Cleaving SNAP25 prevents these
vesicles from fusing with the membrane and prevents the release of acetylcholine into the neuromuscular junction (the
space between the motor nerve and the muscle). Thus, nerve
impulses that control muscle contractions are blocked decreasing muscle activity. Cleaving SNAP25 also blocks release of neuropeptides involved in the transmission of painful
sensations (including substance P, glutamate and cal-citonin
gene-related peptide, or CGRP), theoretically reduc-ing pain
sensitization of peripheral nerves. This may be how BOTOX
reduces the neck pain associated with cervical dys-tonia,
although the exact mechanism of action is unknown.
Phase II. Nerve-Muscle Communication
is restored :
The effect of BOTOX is generally temporary. Previous nerve
impulse activity and associated muscle contractions resume
over the course of a few to several months, depending on the
33
individual patient and the indication for which they are
being treated.
A.
Nerve Sprouting :
New nerve endings sprout and connect to the muscle
after the original nerve ending is blocked, renewing the
ability of the nerve to cause muscle contractions.
B) Original Nerve Connection Re- established :
Eventually, the new nerve sprouts retract and the
original nerve ending regains its function, suggesting
that treatment with BOTOX does not permanently alter
the neuromuscular junction.
Indication :
34
1. Strabismus
2. Cervical dystonia,
3. Blepharospasmand
4. Hemifacialspasm,
5. Hyperfunctionallarynx,
6. Juvenile cerebral palsy
7. Spasticity
8. Pain and headache
9. Occupational dystonia and writer.s cramp,
Uses of botox in dentistry :
1. Tempromandibular disorders
2. Massetric hypertrophy
3. Hemifacial spasm
4. Myofacial pain
5. Bruxism
6. Trismus, sialorrhea
7. Retraining muscles during orthodontic therapy, in
patients with a very strong musculature.
8. Training the patient to get used to new dentures,
especially in patients with strong irregular muscle
contractions, who have been edentulous for a long time and
have old dentures and they are significantly over closed.
9. Jaw line contouring by injecting into masseter muscle
thus weakening it and some bulk of this muscle is
reduced, resulting in a more tapered jaw line.
Procedure for injection :
For correction of gummy smile, Botox is injected into the hyperactive elevator muscles of lip blocking excessive contrac-
35
tions and thus prevent the lip from being pulled too far up while
smiling. It will be important for the patient to avoid taking aspirin
or related products, such as ibuprofen (e.g., Advil) or naproxen if
possible after the procedure to keep bruis-ing to a minimum.
Prior to injection, reconstitute vacuum-dried BOTOX, with sterile
normal saline without a preserva-tive; 0.9% Sodium Chloride
Injection is the only recommended diluents. Draw up the proper
amount of diluents in the appro-priate size syringe, and slowly
inject the diluents into the vial. BOTOX should be administered
within four hours after recon-stitution. During this time period,
reconstituted BOTOX should be stored in a refrigerator (2° to
8°C). Reconstituted BOTOX should be clear, colorless and free
of particulate mat-
ter.
Mario Polo [ 94, 96] has advocated injection of botox at
LLS, LLSAN, LLS /ZM overlaps and in severe cases at
depressor nasii & OO also. The ideal dosage might be 2.5
U per side at the LLS & LLSAN, 2.5 U per side at the
LLS/ZM sites, and 1.25 U per side at the OO sites.
36
Very recently Hwang et al ;[95] Yonsei University College
of Dentistry, Seoul, Korea have proposed a injection point
for botulinum toxin-A, and named it as YONSEI POINT
and they recommend a dose of 3U at each Yonsei Point
Yonsei point is located at the centre of the triangle formed by :
1. levator labii superioris [LLS],
2. levator labii superioris alaeque nasi [LLSAN],
37
3. and zygomaticus minor [Zmi].
How often do patients need to return for
addi-tional injections ?
Effect of Botox is seen within 5-10 days and lasts about 6
months, with a range of 4 to 8 months, at which time the patient can return to repeat the process. It is important not to give
injections prematurely (before the effects of the treatment have
worn off), as this can result in a buildup of antibodies to Botox
that would dilute the effect of further treatments.
Contraindications :
1. During pregnancy or while breast feeding
2. Presence of inflammation or infection at the site of
proposed injection
3. Anyone with known hypersensitivity or allergies to
human albumin, Botox toxin, or saline solution.
4. Anyone with known motor neuropathy, neuromuscular disorders such as amyotrophic lateral sclerosis, myasthenia
38
gravis, Lambert-Eaton Syndrome, muscular dystrophy,
multi-ple sclerosis etc.
5. Anyone taking Aminoglycoside antibiotics because
amino-glycosides may interfere with neuromuscular
transmission and potentiate the effect of Botox therapy.
6. Anyone taking Calcium Channel Blockers.
Side effects :
1. Nausea
2. Localized pain
3. Infection
4. Inflammation
5. Tenderness
6. Swelling
7. Redness, and/or
8. Bleeding/bruising
Disadvantages :
1. Short term effect
2. Asymmetrical/unnatural appearance of smile sometimes
due to improper injection technique
3. Cost factor
Advantage :
1. Psychological benefit to the patient
2. Minimally invasive
39
Filler :
The perioral region is the framework through which the teeth
appear [97]. Well- defined and full lips give a youthful and attractive appearance .[97] A variety of absorbing and permanent fillers were used to shape the lips [ 98]. In recent
years[ 97,98] , the fillers derived from hyaluronic acid have become the most effective medium to correct soft tissues, and the
best filler for lips augmentation[99] . there are two essential
points to observe: the first is the shape of the lips and the second is their relationship with the other parts in the lower third of
the face, especially the support provided by the bone struc-tures
and teeth [100]. Lip augmentation includes the reshaping and /
or increasing the size of the visible part of the lips, the
vermilion, changing the shape of the Cupid’s bow and the relationship between the vermilion and the skin below the columella of the nose, all of which is considered within lip filling
[98] . The lips augmentation can be done using either
surgical or injection procedures to increase the size and
obtain well-de-fined borders of the lips[ 101] . Fillers are
products that are in-jected into soft tissues to increase
volume, correct defects, fill wrinkles, and shape the face.
Fillers are classified into :
40
absorbent and non-absorbent (permanent) materials, and may
also be classified according to the injection site (within the
dermis or under the skin), to the source of the material (autogenous, animal, industrial, semi-industrial) or to the duration
of its effect (temporary: less than six months, long-term: from
six months to two years, semi- permanent: two to five years,
permanent: more than five years) [102] . Today, hyaluronic
acid is commonly used to fill the lips due to its hydrophilic
proper-ties and the natural appearance that it gives. Its effect
lasts be-tween 3 and 6 months and can continue in some
patients for extended periods of time . [103]
Mercado-Rosso classification of gummy smile :
According to the Mercado-Rosso classification, gummy smile
is divided into three different types: Type 1, char- acterized by
a lack of support and/or a lack of projection of the upper maxilla. This type is defined by a thin white lip, associated with the
presence of perioral wrinkles (barcode). Type 2, character-ized
by a deep pyriform fossa, thickness of the upper lip is slightly
greater, fewer skinfolds and wrinkles, and a higher lip
elevation at the areas of the 12th and 13th, as well as 22th and
23th dental pieces due to an imbalance between the strength
(excess) of the levator muscles and the resistance (defect) of
the soft tissue. Finally, the type 3 is defined by an excessive
strength of the zygomatic muscles, which causes a wide smile
and an excessive .
41
Treatment approach of gummy smile with hyaluronic acid
fillers according to the Mercado-Rosso classification :
The therapeutic approach proposed is based on the concept
of RD Dynamic Restructuring . RD Dynamic Restructuring
makes reference to the action of the HA fillers on the muscle
movement, looking for balance between the muscle activity
and different facial structures (bone, superficial musculoaponeurotic system, subcutaneous cellular tissue, and
skin), by stretching the ligaments or increasing the
resistance of the soft tissues to be folded.
42
Treatment of gummy smile type 1 :
As aforementioned, according to the Mercado-Rosso
clas- sifi-cation, the gummy smile Type 1 is characterized
by a lack of structural support. In this type of gummy
smile the treatment strategy is:
• Administration system Blunt microcannula (25G
and 50 mm).
• Hyaluronic acid 23 mg/mL.
• Depth Deep Supramuscular and/or in a multilayer approach.
• Total amount 0.6 mL of HA per side, distributed in 12
retro-grade injections (0.05 mL per application) per side.
• Treated area The whole white lip, from the
entrance to piriformis fossa to the midline.
At approximately 5 mm of the corner of the mouth, by means a
blunt microcannula (25G and 50 mm), with a retrograde fanning technique from the entry point to the piriformis fossa to
the midline, 0.6 ml of HA (23 mg/mL) is injected at a supramuscular plane. The purpose is to act on the entire white lip, with
the objective of providing (and/or recovering in those cases
with aging changes) structural support. The objective is cor-
43
recting the projection deficit and to increase the
resistance of the white lip to be folded.
In those cases, with a major lack of projection of the anterior
nasal spine and/or premaxilla deficiency, it would be necessary
to inject an additional bolus of HA (23 mg/ ml) (Teosyal RHA4,
Teoxane, Geneve, Switzerland) in the premaxilla area, at the
projection of the anterior nasal spine at the supraperiostium
level . In other cases, upon reaching the central region of the
white lip, it would be preferable to leave small boluses at the end
of each fanning retrograde administration (circumscribed to the
edges of the insertion of the nasal wings).
Lower image: The recommended : strategy is 0.6 ml/per side of
high-density hyaluronic acid (HA) filler (RHA4Ò, Teoxane,
Geneve, Switzerland) administered by means fanning retrograde technique with a blunt microcannula. Additionally, small
boluses (blue ellipses) 0.4 mL–0.6 mL de HA 23 mg/mL at
44
the end of each fanning retrograde administration upon
reach-ing the central region of the white lip and
circumscribed to the edges of the insertion of the nasal
wings. a Frontal view. b lat-eral view
Treatment of gummy smile type 2 :
The type 2 gummy smile is mainly defined by an unbalanced activity of the levator muscles. The recommended
treatment strategy is:
• Administration system: Blunt microcannula (25G
and 50 mm).
Hyaluronic acid: 23 mg/mL.
• Depth: Supramuscular /intramuscular
• Total amount:
• A total of 0.2–0.4 mL of HA per side at the piriformis fossa.
• A total of 0.2 mL per side at the levator labii
superioris alaeque nasi.
• A total of 0.1 mL per side at the anterior nasal spine.
• Patient, can also have type 1 in these cases:
• Treated area Piriformis fossa (looking for the Levator
labii superioris muscle).
The injection is administered at approximately 5 mm of the
corner of the mouth, by means a blunt microcannula (25G and
50 mm), with a fanning technique and looking, at the piri-formis
fossa, for a deep plane superficial to levator labii supe-rioris. It
is recommended, before to start the HA administra-tion, that the
patient gesticulates for determining the blunt shifting. Once the
levator labii superioris muscle has been loca- ted, we proceed
to inject a bolus of 0.2 to 0.4 mL of a
45
crosslinked HA filler (23 mg/mL), with the goal of modulate
the muscle activity. As a second step, the canula should be
medial-ly slide, looking for a parallel point, almost under the
nasal wing insertion, which allows to limit the strength of
contrac-tion of the levator labii supe rioris alaeque nasi.
At this point, approximately 0.1 mL of 23 mg/ml HA filler
should be injected. Finally, sliding the blunt micro- cannula to
the nasal spine, but without touching it, 0.2 mL of 23 mg/ml
HA filler needs to be placed on the depressor septi nasi
muscle Once the effect of RD Dynamic Restructuring on the
gingival smile has been observed, it is time to proceed to
treat the un-derlying Type 1 gummy smile, as appropriate.
Treatment of gummy smile type 3 :
There is an overactivity of the zygomatic muscles. The
recom-mended treatment strategy is:
Administration system: Needle (27G and 30 mm).
Hyaluronic acid: 25 mg/mL.
Depth: Periosteum.
Total amount: 0.4 mL–0.8 mL of HA per side, distributed
in 2 boluses (0.2 mL–0.4 mL/per bolus/per side).
46
Treated area: Malar region.
Patient, can also have type 1 o 2 characteristics,
47
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