The effect of a combination of clinical crown lengthening surgery and botulinum toxin A injection in gummy smile treatment

Abstract

In many cases, the cause of a gummy smile is not single but a combination of many factors affecting it simultaneously. Therefore, relying on a single method will be difficult to treat comprehensively and achieve the maximum aesthetic requirements for the patient. This study aims to evaluate the efficacy of a combination of a clinical tooth crowns lengthening surgery following by a BTX-A injection in gummy smile treatment upon based on clinical assessment and photography. 21 patients aged from eighteen years with an average length of excessive gingival display ≥ of 4 mm when maximum smiling and the height of keratinized gingiva ≥ 3 mm were recruited. The gingival exposure (GE) and the clinical crown length (CCL) were measured at baseline T0, two months after performing clinical crown lengthening surgery (T1), two weeks after BTX-A injection (T2), two months after BTX-A injection (T3). The GE in individual teeth after crown lengthening surgery (T1) and BTX-A injection after two weeks (T2) and two months (T3) were significantly different (p <0,001). The CCL was significantly changed after gingivectomy surgery (T1) compared to preoperative (T0) (p <0.001). BTX-A could be considered as a favorable adjunctive treatment for gummy smile patients after gingivectomy surgery.

Keywords

• crown lengthening
• smiling
• injection
• botulinum toxin A

References

1. 1. Little AC, Jones BC, DeBruine LM. Facial attractiveness: evolutionary based research. Philos Trans R Soc Lond B Biol Sci. 2011;366(1571):1638-59. Epub 2011/05/04. doi: 10.1098/rstb.2010.0404. PubMed PMID: 21536551; PubMed Central PMCID: PMCPMC3130383.
2. 2. O'Doherty J, Winston J, Critchley H, Perrett D, Burt DM, Dolan RJ. Beauty in a smile: the role of medial orbitofrontal cortex in facial attractiveness. Neuropsychologia. 2003;41(2):147-55. Epub 2002/12/03. doi: 10.1016/s0028-3932(02)00145-8. PubMed PMID: 12459213.
3. 3. Oliveira M, Otoboni Molina G, Furtado A, Ghizoni J, Pereira J. Gummy smile: A contemporary and multidisciplinary overview. Dental Hypotheses. 2013;4:55-60. doi: 10.4103/2155-8213.113014.
4. 4. Dym H, Pierre R, 2nd. Diagnosis and Treatment Approaches to a "Gummy Smile". Dent Clin North Am. 2020;64(2):341-9. Epub 2020/03/01. doi: 10.1016/j.cden.2019.12.003. PubMed PMID: 32111273.
5. 5. Horn S, Matuszewska N, Gkantidis N, Verna C, Kanavakis G. Smile dimensions affect self-perceived smile attractiveness. Scientific reports. 2021;11(1):2779. Epub 2021/02/04. doi: 10.1038/s41598-021-82478-9. PubMed PMID: 33531621; PubMed Central PMCID: PMCPMC7854600.
6. 6. Kokich V. Adjunctive Role of Orthodontic Therapy. 2012. p. 505-6.
7. 7. Seixas M, Costa-Pinto R, Araújo T. Checklist of aesthetic features to consider in diagnosing and treating excessive gingival display (gummy smile). Dental Press Journal of Orthodontics. 2011;16. doi: 10.1590/S2176-94512011000200016.
8. 8. Sundaram H, Huang PH, Hsu NJ, Huh CH, Wu WT, Wu Y, et al. Aesthetic Applications of Botulinum Toxin A in Asians: An International, Multidisciplinary, Pan-Asian Consensus. Plast Reconstr Surg Glob Open. 2016;4(12):e872. Epub 2017/03/16. doi: 10.1097/GOX.0000000000000507. PubMed PMID: 28293488; PubMed Central PMCID: PMCPMC5222633.

9. 9. 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. Epub 2009/01/07. doi: 10.2319/091407-437.1. PubMed PMID: 19123705.
10. 10. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):24-8. Epub 1984/01/01. doi: 10.1016/s0022-3913(84)80097-9. PubMed PMID: 6583388.
11. 11. Ahmed N, Halim MSB, Ghani ZA, Khan ZA, Abbasi MS, Jamayet NB, et al. A 2D Photographic and 3D Digital Dental Model Analysis of Golden Percentage in Maxillary Anterior Teeth. BioMed research international. 2021;2021:6674400. Epub 2021/05/11. doi: 10.1155/2021/6674400. PubMed PMID: 33969123; PubMed Central PMCID: PMCPMC8081617.
12. 12. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18-28. Epub 1996/06/01. doi: 10.1111/j.1600-0757.1996.tb00179.x. PubMed PMID: 9567953.
13. 13. Silva CO, Ribeiro-Junior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: treatment by a modified lip repositioning technique. J Clin Periodontol. 2013;40(3):260-5. Epub 2013/01/03. doi: 10.1111/jcpe.12046. PubMed PMID: 23278672.
14. 14. Fradeani M. Evaluation of dentolabial parameters as part of a comprehensive esthetic analysis. Eur J Esthet Dent. 2006;1(1):62-9. Epub 2006/04/01. PubMed PMID: 19655476.
15. 15. Miron H, Calderon S, Allon D. Upper lip changes and gingival exposure on smiling: vertical dimension analysis. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2012;141(1):87-93. Epub 2011/12/27. doi: 10.1016/j.ajodo.2011.07.017. PubMed PMID: 22196189.
16. 16. Maynard JG, Jr., Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. Journal of periodontology. 1979;50(4):170-4. Epub 1979/04/01. doi: 10.1902/jop.1979.50.4.170. PubMed PMID: 286038.
17. 17. Tawfik OK, El-Nahass HE, Shipman P, Looney SW, Cutler CW, Brunner M. Lip repositioning for the treatment of excess gingival display: A systematic review. J Esthet Restor Dent. 2018;30(2):101-12. Epub 2017/12/02. doi: 10.1111/jerd.12352. PubMed PMID: 29193632.
18. 18. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Journal of periodontology. 1992;63(12):995-6. Epub 1992/12/01. doi: 10.1902/jop.1992.63.12.995. PubMed PMID: 1474471.
19. 19. Cengiz AF, Goymen M, Akcali C. Efficacy of botulinum toxin for treating a gummy smile. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2020;158(1):50-8. Epub 2020/05/18. doi: 10.1016/j.ajodo.2019.07.014. PubMed PMID: 32414547.
20. 20. Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics. 2008;133(2):195-203. Epub 2008/02/06. doi: 10.1016/j.ajodo.2007.04.033. PubMed PMID: 18249285.
21. 21. Suber JS, Dinh TP, Prince MD, Smith PD. OnabotulinumtoxinA for the treatment of a "gummy smile". Aesthet Surg J. 2014;34(3):432-7. Epub 2014/03/29. doi: 10.1177/1090820X14527603. PubMed PMID: 24676413.
22. 22. 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. Epub 2010/11/26. doi: 10.1016/j.jaad.2010.02.053. PubMed PMID: 21093661.
23. 23. Brookes ZLS, Bescos R, Belfield LA, Ali K, Roberts A. Current uses of chlorhexidine for management of oral disease: a narrative review. Journal of dentistry. 2020;103:103497. Epub 2020/10/20. doi: 10.1016/j.jdent.2020.103497. PubMed PMID: 33075450; PubMed Central PMCID: PMCPMC7567658.