Currently, the demand for cosmetic procedures has grown exponentially. Dental procedures, as well as medical ones, besides working to obtain the principle of health promotion, seek smile esthetics, as the smile is a form of communication and socialization that expresses many feelings (
Facial esthetic harmony correlates directly with the smile and this, in turn, is formed by the union of three components: teeth, gum and lips (
Several therapeutic modalities have been proposed for the correction of gummy smile, among them: gingivectomy or gingivoplasty (
Botulinum toxin is synthesized by Gram-positive anaerobic bacterium
Currently, botulinum toxin has been shown effective in the treatment of gummy smile in patients with hyperfunction of the muscles involved in smiling, as well as in patients with other disorders such as temporomandibular disorders (hypertrophy of the masseter muscle, bruxism, clench) and myofascial pain (
A Caucasian female, 28 years old, attended the particular clinic complaining gummy smile. Clinically, the patient presented severe anatomic discrepancy between the length of the maxillary teeth (
The gingivoplasty was proposed. Before the surgical procedure, the patient was oriented about oral hygiene, in order to reduce gingival inflammation and prevent the possibility of recurrence of gingival overgrowth.
Under local infiltrative anesthesia, gingivoplasty was performed by determination of the bleeding points with the aid of a millimeter probe and the union of these points was made with the electric scalpel (
After 30 days, satisfactory tissue repair was observed (
Prior to application of botulinum toxin, the surface of the skin was disinfected with ethanol, to avoid local infection and remove the oils from the skin. Posteriorly, local anesthetic (Emla®, Astra, Sao Paulo, Brazil) was applied, with the purpose to promote comfort during the procedure. The botulinum toxin type A (Dysport®, Ipsen Biopharm Ltd, Wrexham, UK) was diluted in 1.7 ml of saline, according to the manufacturer’s instructions, and injected 2 units at the recommended site, laterally to each nostril. After application, the patient was advised do not lower her head and not engage in physical activity during the first 4 hours after the procedure.
After 10 days, the patient was evaluated presenting uniform dehiscence of the upper lip (
Botulinum toxin has become an excellent auxiliary mean in the treatment of several dental disorders. Despite being known for cosmetic use in the reduction of hyperkinetic facial lines, it can also be used for therapeutic purposes in cases of bruxism, temporomandibular joint dysfunction, masseter hypertrophy and severe gingival exposure (
The gummy smile is conceptualized by the exposure of more than 3 mm of gingival tissue during smiling (
Several etiologies have been suggested to gummy smile, as vertical maxillary excess (
In gummy smile caused by overactive muscle, botulinum toxin was indicated. It is the treatment of first choice for the ease and security of applications, quick effect, besides being a more conservative approach when compared to surgical procedures (myectomy or Le Fort I osteotomy) (
The activity of the smile is determined by several facial muscles, like the elevator of the upper lip and wing of the nose, the zygomatic major and minor, the angle of the mouth, orbicularis oris and risorius (
Each muscle involved in the elevation of the upper lip has a function during the activity of smile. The points of the injections are determined by the contraction of specific muscle groups, that results in different areas of gingival display. Several classifications have been proposed to gummy smile: anterior, posterior, mixed and asymmetric, involving different muscle groups (
Botulinum toxin type A is a hydrophilic powder, stored under vacuum, sterile and stable (
At the beginning of the treatment, extraoral photographs, including the close-up of the smile, were performed. Some authors mentioned the importance of taking the picture of the smile before and after the application of the toxin (
The clinical effects show up in 2-10 days after the injection, and the most visible effect occurs 14 days after the injection (
The injection of botulinum toxin, despite being a simple and safe procedure, may be associated with some adverse events such as: Pain at the injection site, bruising, infection, edema, dysphonia, dysphagia, ptosis or lengthening of the upper lip and asymmetry of the smile. The dentist should be attentive in relation to dosage, precision of technique and location of the puncture (
Contraindications to the use of botulinum toxin are: pregnancy; lactation; hypersensitivity (allergy) to botulinum toxin itself; lactose and albumin; muscle and neurodegenerative diseases (myasthenia gravis and Charcot’s disease); and concurrent use of aminoglycoside antibiotic that enhances the action of the toxin (
In this report, the result was satisfactory to the harmony of the smile of the patient by association of treatments - gingivoplasty and application of botulinum toxin type A. The institution of isolated treatments could not culminate in the excellence of the earned results. Initially, the creation of the new dental zenith during the course of resective gingival surgery promoted the new dental architecture, favoring harmony gingival-dental-facial for the patient. Subsequently, the application of botulinum toxin type A softened the gummy smile, by the uniform dehiscence itself of the upper lip, still promoting smoothness to facial lines of the smile, as can be seen in the nasolabial folds, adjacent to the nostrils, comparing
The application of botulinum toxin is an alternative less invasive, faster, safer, more effective and it produces harmonics and pleasing results when applied in target muscles, respecting the appropriate dose and type of smile, and, therefore, it is a useful adjunct in the esthetic improvement of the smile and provides better results when combined with resective gingival surgery.
Based in this case report, future researches become important for the clinical evidence of this therapeutic association.
Research article.