SHORT COMMUNICATION

Botulinum toxin type A in the treatment of

excessive gingival display
Mario Polo
San Juan, Puerto Rico

Purpose: One cause of excessive gingival display is the muscular capacity to raise the upper lip higher than
average. Several surgical procedures have been reported to improve the condition, but surgery always
involves risk and is costly. Botulinum toxin type A (BTX-A) (Botox; Allergan, Irvine, Calif) has been studied
since the late 1970s for the treatment of several conditions associated with excessive muscle contraction or
pain. This clinical pilot study was performed to determine whether BTX-A injections would reduce excessive
gingival display. Material: Five subjects with excessive gingival display due to hyperfunctional upper lip
elevator muscles were treated with BTX-A injections. Results: This treatment modality was effective,
producing esthetically acceptable smiles in these patients. The improvements lasted 3 to 6 months.
Conclusions: Injection with BTX-A at preselected sites is a novel, cosmetically effective, minimally invasive
alternative for the temporary improvement of gummy smiles caused by hyperfunctional upper lip elevator
muscles. (Am J Orthod Dentofacial Orthop 2005;127:214-8)

Kostianovsky13 described a procedure whereby an

T
he display of excessive gingival tissue in the
maxilla upon smiling has been called a “gummy
smile,” a condition some consider esthetically
displeasing. Some people with excessive gingival dis-
play are self-conscious or embarrassed about it, and
some are psychologically affected.1 Although the inci-
dence of excessive gingival display has not been
established, it is fairly common. Etiologic factors can
be skeletal, gingival, muscular, iatrogenic, or some
combination of these. The literature contains many
reports that address the skeletal problem of vertical
maxillary excess2-6 and gingival problems related to
delayed passive eruption.7-9 In his review of structural
esthetic rules, Rufenacht10 referred to this condition.
Robbins11 reported differential diagnosis and treatment
of excessive gingival display.
The muscular capacity to raise the upper lip higher
than average (hyperfunctional muscle) can cause exces-
sive gingival display.12 Upper lip elevator muscles
include the levator labii superioris, levator labii supe-
rioris alaeque nasi, levator anguli oris, zygomaticus
major, zygomaticus minor, and the depressor septi nasi.
Several surgical procedures have been reported in the
literature to correct a gummy smile caused by hyper-
functional upper lip elevator muscles (mostly the
levator labii superioris muscles). Rubinstein and
Medical faculty orthodontist, Department of Surgery, San Jorge Children’s
Hospital/Plastic and Reconstructive Center, San Juan, Puerto Rico.
Reprint requests to: Dr Mario Polo, 702 La Torre de Plaza, 525 F.D. Roosevelt
Ave, San Juan, Puerto Rico 00918-0702; e-mail, smiledesigner@caribe.net.
Submitted, May 2004; revised and accepted, September 2004.
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.09.013
214
elliptical portion of gingiva and buccal mucosa was
excised and the borders approximated and sutured
together. Litton and Fournier14 referred to “muscle
detachment from the bony structures above” to bring
the lip down. Miskinyar15 used a different surgical
technique to treat 27 patients, including 7 who had
relapsed after being treated with the Rubinstein and
Kostianovsky technique. Miskinyar claimed only “a
minor success rate, and even complete disappointment
with previous techniques.” In his new technique, he
performed myectomy and partial resection of the leva-
tor labii superioris muscles; 1 or both of the bellies of
the muscles were amputated 1.0 to 2.0 cm at their
junction with the orbicularis oris muscle. No reference
was made to a skeletal etiology for the problems, as
stated by Sullivan,16 and no follow-up time was dis-
cussed. Ellenbogen17 reported that resection of the
levator labii superioris is short-lived, with the gummy
smile returning within 6 months. He advocated placing
a spacer, either nasal cartilage or prosthetic material,
between the stumps to prevent the muscles from being
reunited and again hyperelevating the lip. Miskinyar18
stated that patients he followed for as long as 8 years
showed no recurrence or disappointing results,15 but he
also pointed out possible disadvantages with the spacer
technique: migration of the spacer to an undesired site
and the muscle ends reuniting, rejection of a foreign
body (in the case of prosthetic spacers), and the need
for a second surgical procedure if nasal cartilage is
used. Rees and LaTrenta19 described a camouflage
procedure through the columella, whereby a subperios-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 127, Number 2
teal dissection of the upper lip elevators was performed.
Ezquerra et al20 presented a multidisciplinary approach
for treating a high smile line with excessive gingival
display: either LeFort I osteotomy or gingival and
alveolar bone remodeling surgery, or a modified (in-
traoral) camouflage procedure as described by Rees and
LaTrenta,19 or a combination of the latter 2.
A nonsurgical alternative for reducing excessive
gingival display caused by muscle hyperfunction would
be advantageous. Botulinum toxin has been under
clinical investigation since the late 1970s for the
treatment of several conditions associated with exces-
sive muscle contraction or pain.22 Botulinum toxin is
produced by the anaerobic bacterium Clostridium
botulinum. There are 8 different serotypes of botulinum
toxin. Type A (BTX-A) is the most potent and the most
commonly used clinically. Botox (Allergan, Irvine,
Calif) is a purified BTX-A isolated from the fermenta-
tion of C botulinum. It is a stable, sterile, vacuum-dried
powder that is diluted with saline solution without
preservatives. BTX-A weakens skeletal muscles by
cleaving the synaptosome-associated protein SNAP-25,
thus blocking the release of acetylcholine from the
motoneuron and enabling the repolarization of the
postsynaptic terminal. As a result, the muscular con-
traction is blocked. The production of acetylcholine is
not affected by this blockade of the neuromuscular
transmission. The effects last 3 to 6 months, although
some investigators have reported a longer duration in
patients exposed over a prolonged period of time.21
BTX-A has been used to treat strabismus,23 cervical
dystonia,24 blepharospasm and hemifacial spasm,25 hy-
perfunctional larynx,26 juvenile cerebral palsy,27 spas-
ticity,28 pain and headache,29 occupational dystonia
and writer’s cramp,30 temporomandibular disorders,31
myofacial pain,32 and oromandibular dystonia and
bruxism,33 and several other conditions. Since 1987,
BTX-A has been widely used for the cosmetic treat-
ment of hyperfunctional facial lines.34
The purposes of this pilot study were to determine
whether BTX-A could also be used in patients with
hyperfunctional upper lip elevator musculature to cor-
rect a gummy smile and to establish the optimal
minimal dose of BTX-A needed to obtain cosmetically
pleasing results.
MATERIAL AND METHODS
Twelve women with excessive gingival display
were screened, and 5 were selected for this study. They
ranged in age from 16 to 23 years. Cephalometric
analysis was performed to determine whether the
gummy smile was skeletal (ie, vertical maxillary ex-
cess). Periodontal evaluation was performed to rule out
Polo 215
delayed passive eruption leading to excessive gingival
display. These patients had a history of fairly good oral
hygiene, although mild gingivitis was acceptable. Some
were receiving active orthodontic treatment. Informa-
tion about the procedure, its possible benefits, risks, and
side effects, and the expected duration of the results, if
any, was given in detail to the patients and the parents
of the minors verbally and in writing. All agreed to
participate. Written informed consent was obtained.
The study was divided into 3 phases. At the beginning
of phase I, extraoral photographs were taken, including a
close-up photograph with a ruler placed vertically at the
facial midline while the patient was smiling (Fig 1). The
spot where the superior portion of the ruler barely touched
the midline of the columella’s most inferior portion at the
nasolabial junction was designated reference point 1
(RP1). The ruler passed through the middle of the phil-
trum and extended inferiorly into the midline of the chin.
The incisal edge of the maxillary right central incisor
along its mesial surface at the midline was designated
reference point 2 (RP2). The distance between the refer-
ence points was constant for each subject when the
full-smile photographs were taken; minor variations (1.0
mm or less) between RP1 and RP2 measurements taken
before and after the procedure were compensated for
when they were recorded.
Injections were made intramuscularly under elec-
tromyographic guidance.35 BTX-A was diluted by add-
ing 4.0 mL of 0.9% normal saline solution without
preservatives to 100 U of vacuum-dried C botulinum
type A neurotoxin complex, according to the manufac-
turer’s dilution technique. This resulted in a 2.5 U/0.1
mL dose. After carefully reviewing the literature for
small muscle dosage, a dose of 1.25 U per muscle site
per side was selected as a baseline to start the study.
Under sterile conditions, 1.25 U per side was injected in
both the right and left levator labii superioris and
levator labii superioris alaeque nasi muscles (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. During this phase, patient 1 received
an additional 1.25 U per side at the origin of the
depressor septi nasi muscle at the orbicularis oris
muscle (OO), 2 to 3 mm inferior to the nostrils and 2 to
3 mm from the midline.
The patients were clinically evaluated 1 week, 2
weeks, 4 weeks, and 16 weeks postoperatively. During
the first evaluation, they were asked to report any
adverse reactions or side effects associated with the
procedure. They also reported how long after the
procedure they started noticing the effects on their
216 Polo
Fig 1. Drawing with landmarks and close-up smiling photos with ruler at facial midline.
upper lips and smiles. During the 2-week evaluation, in
addition to reviewing again for adverse reactions and
onset of changes, subjects were evaluated to determine
whether the results obtained were sufficient or whether
additional muscular weakness by reinjection was desir-
able.
Phase II of the study began 1 month later. After
determining 2 weeks postoperatively that additional injec-
tions could enhance the results, it was decided to inject the
LLS and the LLS/ZM with a supplemental dose of
BTX-A. All patients agreed to undergo this second ses-
sion. The subjects received 0.625 U per side at the
LLS/ZM sites and either 1.25 U or 0.625 U at the LLS
sites. The latter was determined by clinical evaluation of
each patient’s results observed from phase I. The patients
were clinically evaluated 2 weeks, 4 weeks, and 16 weeks
postoperatively after the phase II injection. Facial photo-
graphs were obtained at the 2-week postoperative visit.
During the 16-week follow-up visit, the patients were
evaluated for evidence of lasting or remaining effects.
Phase III of the study followed a similar protocol,
except that all patients received 2.5 U injections per
side at the LLS and LLS/ZM sites. Patients 1 and 4 also
received 1.25 U per side at the OO site described above.
They had the greatest amount of upper lip elevation
near the philtrum. They were then evaluated 2 weeks, 4
weeks, and 16 weeks postoperatively. Photographs
were obtained at the 2-week postoperative visit.
One patient requested an additional treatment. She
received 1.5 U per side at LLS and LLS/ZM sites and
1.25 U per side at OO sites 3 months after the phase III
injection. She received these lower doses because she
was experiencing residual effects from her last BTX-A
administration, but she nevertheless wanted to enhance
the results previously achieved.
RESULTS
The results of this pilot study were analyzed both
subjectively, by clinical evaluation of the gummy
American Journal of Orthodontics and Dentofacial Orthopedics
February 2005
smile, and objectively, with pre- and postoperative
photographs (Fig 2).
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 the maxillary
right central incisor crown along its own midline.
All 5 patients began to show improvement approx-
imately 10 days after the injections. After 14 days,
results were definitely observed. The pre- and postop-
erative measurements were recorded and compared. At
2 weeks after injection in phases II and III, all 5 patients
had a mean increase of measurements A and B of 4.20
mm and a mean decrease of measurement C of 4.20
mm (Table I).
The effective increase in upper lip length upon
smiling was 131%, 120%, 124%, 117%, and 129%
(mean, 124.2%) for patients 1 through 5, respectively.
Gingival exposure went from 4.0 mm to 0 mm for
patients 1 and 3, from 4.0 mm to 1 mm for patient 4,
and from 5.0 mm to 0.0 mm for patients 2 and 5. There
was no significant difference in the measurements
between phase II and phase III. Patients 2 and 5 showed
the greatest improvement, as determined by the mea-
surements, followed by patient 1. Patients 1 and 4
received the injection at the OO site; however, patients
2 and 5 showed the greatest amount of improvement.
DISCUSSION
All patients were pleased with the results. No side
effects (infection, bruising, edema, or loss of muscle
strength) were reported or observed. One patient re-
ported mild pain during the injection procedure. The
effect began to be noticeable approximately 10 days
after injection, with the maximum noticeable effect
about 14 days after injection. This effect was reported
to be progressive but also reversible, lasting 3 to 6
American Journal of Orthodontics and Dentofacial Orthopedics Polo 217
Volume 127, Number 2

Table. Linear measurements: phase III

Measurement (mm)

Patient no. A B C ⌬A (mm) ⌬C (mm)

1 Preoperative 8.0 5.0 4.0 4.0 ⫺4.0

Postoperative 12.0 5.0 0.0
2 Preoperative 9.0 6.0 5.0 5.0 ⫺5.0
Postoperative 13.0 6.0 0.0
3 Preoperative 12.0 5.0 4.0 4.0 ⫺4.0
Postoperative 16.0 5.0 0.0
4 Preoperative 12.0 6.0 4.0 3.0 ⫺3.0
Postoperative 15.0 6.0 1.0
5 Preoperative 9.0 8.0 5.0 5.0 ⫺5.0
Postoperative 14.0 8.0 0.0

See text for definitions of measurements A, B, and C.

months. The patients received a supplemental dose 1

month after the initial baseline dose in phase I.
The results obtained from phase III were highly
acceptable, and that dosage could be the optimal dose
for achieving the expected results. Clinical judgment
should always be exercised when selecting the injection
sites. In severe cases, injecting at the OO site should be
clinically considered, because the depressor septi nasi
muscle, also associated with elevating the upper lip
near the midline, inserts into the fibers of the OO
muscle. The depressor septi nasi muscle thus has a
vertical pull component on the OO. The zygomaticus
major muscle was not included in this study but will be
in a subsequent study now underway.
Although surgical techniques have been reported in
the literature, they are not routinely used to treat
hyperfunctional upper lip elevator muscles resulting in
a short upper lip and a concomitant gummy smile. Most
of the surgical correction currently used seems to be
LeFort I maxillary osteotomies with impaction for
skeletal vertical maxillary excess and gingivectomies
for delayed passive dental eruption with excessive
gingival display.
Because BTX-A is used frequently for the tempo-
rary correction of perioral rhytides, care should be
taken when injecting these anatomical areas in patients
with hypotonic, flaccid lips to avoid further muscle
weakening and an esthetically unacceptable smile be-
cause of excessive soft tissue covering the smile line.

CONCLUSIONS
Injection with BTX-A provides effective, mini-
mally invasive, temporary improvement of gummy

Fig 2. Pretreatment and posttreatment photographs of

study subjects.
218 Polo
smiles for patients with hyperfunctional upper lip
elevator muscles. The ideal dosage might be 2.5 U per
side at the LLS, 2.5 U per side at the LLS/ZM sites, and
1.25 U per side at the OO sites. Future studies are
needed to assess this treatment in a much larger sample.
I thank Gishlaine Alfonso, MD, neurologist, for her
teaching and training of the electromyographically
guided injection technique of BTX-A.
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