BUJOD 2014-may-13

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Extensive exposure of the gingiva during a smile, called excessive gingival display, ... displayed upon full smile, it is termed a gingival smile or Gummy smile.
BUJOD Case Report TREATMENT OF GUMMY SMILE USING BOTULINUM TOXIN TYPE-A (CASE REPORT) Authors: Vaibhav Joshi*, Shweta Bali**, PriyankaThukral***, DeepaVerma**** ABSTRACT Extensive exposure of the gingiva during a smile, called excessive gingival display, may be a cause of concern for both patients and clinicians.When an excess of gingiva superior to the maxillary anterior teeth is displayed upon full smile, it is termed a gingival smile or Gummy smile. Treatment modalities for gummy smile change according to its etiology.This article examines a non-surgical treatment option for reducing the excessive gingival display ('gummy smiles'), which can be found in many patients. Botulinum toxin type A (BTX-A) (Botox; Allergan) has been studied since the late 1970s for the treatment of several conditions associated with excessive muscle contraction. If carefully administered, this procedure is a very quick, reliable and predictable treatment option for most appropriate cases and should be considered as a viable modality before embarking on any anterior cosmetic dentistry or indeed facial aesthetic treatment for the lips themselves. Keywords: Gummy smile, Botox, Gingivectomy. INTRODUCTION Gummy smile is defined as the exposure of excessive gingival tissue in maxilla. Some people with excessive gingival display are self-conscious or embarrassed about it, and some are psychologically affected. Etiological factors involved in the formation of gummy smile can be -Skeletal (vertical maxillary excess), Gingival (passive eruption) or Muscular (hyper functional upper lip) and treatment options range from Le fort I osteotomy, crown lengthening, intrusion, myectomy to muscle resection etc. (Table 1-2). Treating patients with a high lip line has always added to the complexity of the cosmetic dental case. Apart from the obvious unaesthetic appeal of an excessive gingival display in the smile, the skill of both dentist and technician are put to the ultimate test to ensure that the margins of the in- direct restorations placed are undetectable. Fortunately, you have several options. To correct the balance between gum size and tooth area, you can go with the non-surgical option, Botox, or one of the surgical options, like a gingivectomy.The exact cause of your gummy smile usually dictates the procedure ADDRESS FOR CORRESSPONDENCE: Dr. Vaibhav Joshi R 6/171 Raj Nagar Ghaziabad, UP-201001.

you will use to correct it. A Botox injection is best for when your upper lip raises to an extreme degree when you smile. Botox weakens the response of muscles to nerve signals, so when you smile, your muscle response will be less severe. If you're experiencing a gummy smile because you have a small amount of excess gum tissue, a gingivectomy may be a better option. Also called a gum lift or gingival contouring, this surgical procedure involves the removal of gum tissue.

Table 2. Treatment alternative for gummy smile Level I

2 to 4 mm of gingival display

Level II

4 to 8 mm of gingival display

Level III

More than 8 mm of gingival display

· Orthodontic intrusion only · Combination of orthodontics and periodontics · Orthodontics, Periodontics and Restorative Therapy · Periodontics and Restorative therapy · Orthognathic surgery · Orthognathic surgery with or without adjunct periodontal or prosthetic therapy

*Sr Lecturer, **Professor, Department of Periodontics, Santosh Dental College, Ghaziabad. ***Professor, Department of Prosthodontics, Santosh Dental College, Ghaziabad. ****Professor, Department of Orthodontics, Santosh Dental College, Ghaziabad. MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY

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BUJOD Botox is indicated when the gummy smile is due to hyper functional upper lip elevator muscles (muscular capacity to raise the upper lip is higher than average). Muscles responsible for upper lip movement during smile are: 1. Levatorlabiisuperioris(LLS) 2.Levatorlabiisuperiorisalaequenasii(LLSAN) 3.Zygomaticusmajor 4. Zygomaticus minor 5.Depressor septii (Figure 1)

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without affecting the rest position of the upper lip (Figures 2). In this way, not only can the lip aesthetics be maintained, but the phonetics are unaffected by the carefully controlled chemodenervation of the selected muscles.

Figure 2

In this article we have discussed two cases with Gummy Smile treated with the administration of Botox. CASE REPORTS The following cases will demonstrate the concept of using BTX for reducing an excessive gingival display. Case 1 (Figures 2-3)Sunanda, a 26-year-old GDP from New Delhi, presented to me with a desire to minimise her 'gummy smile.' On examination, an average of 7mm gingival display was recorded at maximal smile. This was measured from the midpoints of the free gingival margins of the central incisors and canines on both sides to the lower border of the upper lip. Naturally, all the possible treatment options available were given to the patient (Table 2) but she was keen to have the noninvasive approach with BTX. In order to 'normalise' the display in this case the levatorlabiisuperious and levatorlabiisuperiorisalaequenasi and depressor septinasi were targeted with intra muscular injections of BTX using a 30 gauge needle. A total dose of 12 I.U Botox was administered. The patient was reviewed after three weeks and the results can be seen in Figure3. The important point to note here is that the goal of treatment was of course to convert the smile to a 'monalisa' smile

Figure 3 Case 2 (Figures4-5) Shikha, a 32-year-old female was presented with a similar complaint. On examination, an average of 7mm gingival display was noted (using the parameters described in case 1). After treatment acceptance the levatorlabiisuperoris and levatorlabiisuperiorisalaequenasi muscles were injected both sides with a total dose of 10 I.U Botox. These muscles were the dominant central elevator muscles in this case (note the excessive elevatory pull in the canine regions compared to case 1). The depressor septinasi was not targeted here as it was felt that if treated this may have contributed to a further nasal lip elevation and unaesthetic larger nasio labial angle. The patient was reviewed after three weeks and the result is shown in Figure 5. The smile dynamics were fully normalised without affected the rest position and phonetics.

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BUJOD 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. 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 Figure 4

Figure 5 DISCUSSION An accurate and comprehensive assessment of the smile dynamics must be made prior to treatment and particularly prior to any anticipated anterior dental aesthetic treatment. As with other facial muscles, the duration of treatment results with BTX is typically three to four months. However, the patients slowly return to the starting position within the period of time, as opposed to a dramatic return to the day 0 position. An additional observation that has been made is that repeated treatments of BTX lip stabilisation have resulted in sustained results and a lowered required dose of BTX in subsequent treatment episodes. One can postulate that this is due to the induced atrophy of the muscles being targeted coupled with a change in the habitual smile dynamics. Hence, BTX lip stabilisation is certainly a valuable treatment option for both operator and patient. Typically such treatments will take less than a minute to perform, and if carefully conducted in trained hands, is a relatively painless and predictable procedure. What is Botox? Botox is the trade name for the neurotoxin protein botulinum toxin type A produced by fermentation of

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, vacuumdried form without a preservative. Uses 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 contractions 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 bruising to a minimum. Prior to injection,reconstitute vacuum-dried BOTOX, with sterile normal saline without a preservative; 0.9% Sodium Chloride Injection is the only recommended diluents. Draw up the proper amount of diluents in the appropriate size syringe, and slowly inject the diluents into the vial. BOTOX should be administered within four hours after reconstitution. 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 matter. Mario Polo has advocated injection of botox at LLS, LLSAN, LLS /ZM overlap and in severe cases at depressor nasii& OO also. The ideal dosage might be

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BUJOD 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. Very recently Hwang et al ; 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 (Fig-6): 1.levatorlabiisuperioris [LLS], 2.levatorlabiisuperiorisalaequenasi [LLSAN], 3.andzygomaticus minor [Zmi]. 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 gravis, Lambert-Eaton Syndrome, muscular dystrophy, multiple sclerosis etc. 5. Anyone taking Aminoglycoside antibiotics because aminoglycosides 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 Advantages 1.Psychological benefit to the patient 2. Minimally invasive Should dentists administer Botox therapy? With plastic surgeons, dermatologists, internal medicine physicians, obstetricians- gynecologists, ophthalmologists, podiatrists, nurses, physician's assistants, and medical aestheticians (who may not even be medically trained) delivering BOTOX to

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patients in the oral and maxillofacial areas, it is certainly time to recognize that dentists can be just as proficient in injections than any of these healthcare providers as dentists have much expertise in the oral and maxillofacial areas and are also trained to be experts in the muscles of mastication and the muscles of facial expression which routinely receive these treatments. CONCLUSION It is time to broaden our horizons as a profession and use all of the tools available to us. BOTOX therapy is a conservative, minimally invasive treatment that can expand our therapeutic options for the benefit of our patients and is a natural progression of where we are going in the dental industry. These procedures are easy to accomplish by general dentists with proper training. To conclude when compared to other surgical procedures botulinum toxin has been proved to be a minimally invasive, effective alternate for the correction of gummy smile caused by upper lip elevator muscles. Injecting botulinum toxin is a useful adjunctive procedure to enhance aesthetics and to improve patient satisfaction. REFERENCES 1. Peck S, Peck L, Kataja M. Some vertical linear measurements of lip position.Am J OrthodDentofacOrthop 1992; 101:519- 524. 2. Lowe N J. Botulinum toxin type A for facial rejuvenation: United States and United Kingdom perspectives. Dermatol Surg. 1998. 24: 1216. 3. Binder WJ, Blitzer A, Brin MF. Treatment of hyperfunctional lines of the face with botulinum toxin A Dermatol Surg. 1998; 24:1198-1205. 4. Mario polo. Botulinum toxin type A in the treatment of excessive gingival display; AJO DO 2005; 27(2):214-218. 5. Hwang et al. Surface anatomy of the lip elevator muscles fort he treatment of gummy smile using botulinum toxin. Angle Orthod 2009; 79(1): 70-77. 6. Mario Polo. Botulinum toxin types A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile) AJO DO 2008; 133(2):195-203. 7. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod. Dentofacial Orthop.1970; 57 (2):132-

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21. Mazzuco and Hexsel: Gummy smile and botulinum toxin: A new approach based on the gingival exposure area. J AMAcad Dermatol, vol 63, no 6, 1042-1051. 22. Susan Standring: Gray's anatomy; The Anatomical Basis of Clinical Practice, Expert Consult; 40th edition, sep-2008. 23. MARC B. ACKERMAN, JAMES L. ACKERMAN: Smile Analysis and Design in the Digital Era; jco- 2002, vol36, no 4, pg: 221-236. 24. Matthews TG. The anatomy of a smile.J Prosthet Dent. 1978; 39(2):128-134. 25. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol. 2000. 1996; 11: 18-28. Fields HW, Proffit WR, Nixon WL, Phillips C, Stanek E. Facial pattern differences in long- faced children and adults.Am J Orthod. 1984; 85(3):217-223. 26. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation in vertical facial growth and associated variation in skeletal a n d d e n t a l re l a t i o n s . A n gl e O r t h o d . 1971;41(3):219-229. 27. Schendel SA, Eisenfeld J, Bell WH, EpkerBN,Mishelevich DJ. The long face syndrome: vertical maxillary excess. Am J Orthod. Dentofacial Orthop. 1976; 70(4):398408. 28. Woo-Sang Hwang: Surface Anatomy of the Lip Elevator Muscles for the Treatment of Gummy Smile Using Botulinum Toxin. Angle Orthod.2009; 79:70–77. 29. Kate Coleman moriarty: Botulinum Toxin in Facial Rejuvenation; 2006. 30. Mario Polo,Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile)Am J Orthod Dentofacial Orthop 2008;133:195203. 31. A. John Vartanian, Steven H. Dayan: Complications of botulinum toxin A use in facial rejuvenation; Facial PlastSurgClin N Am 13 (2005) 1– 10.

Source of Support :

NIL

Conflict of Interest :

NOT DECLARED

Date of Submission :

05-01-2014

Review Completed :

06-03-2014

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