How to fix a gummy smile with botulinum toxin (Botox)

Many patients seek ways to fix their gummy smile – excessive gingival exposure upon smiling, and botulinum toxin or Botox® is one of the easiest ways to achieve this for them, but treatment indications and patient selection play a significant part in the success of this treatment.

In this blog, Dr Tim Pearce explains when to treat a gummy smile, the anatomy involved, potential side effects, and what to look for in the ideal patient.

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What is a gummy smile?

Approximately 25% of the world’s population is thought to have a ‘gummy smile’. It is defined as a presentation where the top lip is more than two millimetres above the start of the gums.

There are many different treatment options for a gummy smile. Dentists can reduce the gum line by shaving back or contouring the gums to make the teeth longer so less of the gum is visible upon smiling. It can also be treated with dermal filler, but more commonly in medical aesthetics with botulinum toxin.

Why are patients unhappy with having a gummy smile?

Dr Tim explains that there is a spectrum of manifestations of a gummy smile. A small gummy smile may not be regarded as unattractive because it portrays a sense of openness and expressiveness that humans quite like in faces.

However, there comes a point where it becomes either a distraction to those who are observing the smile, or to the person who is smiling, and this can stop the individual from smiling fully. As soon as a patient is self-conscious enough to try not to smile, this is a strong indication for solving the problem aesthetically, allowing them to be in the moment and express themselves more freely.

Why do some patients’ lips move up above their teeth?

This is multifactorial and not only predicated on one answer, notes Dr Tim.

Sometimes, the skeleton is shaped in a certain way, particularly if an individual has strong teeth that are projecting forward. In this case, it is somewhat easier for the lip to fold and slide off the teeth to reveal more of the teeth. On other occasions, it is related to the relative strength of the muscles, the lip elevators compared with the lip depressors, plus the way the skin and muscles are attached around the mouth. This geometry may simply lend itself to pulling too strongly in a superior action.

Some people also develop a gummy smile as they get older. Their face becomes more dynamic, or hyperdynamic as they lose the fat (facial volume) which resists the action of the muscles. Therefore, you might see a 70-, 80-, or 90-year-old person creating a large smile that pulls their mouth right up in a way that a 25-year-old would not, even in the same person, (if you have old photos to compare!) This is why dermal filler – volume replacement – can also be an appropriate treatment for a gummy smile, rather than relaxing the muscle with botulinum toxin.

Typically, Dr Tim would favour treating using botulinum toxin in a younger patient who has a smaller gummy smile and using dermal filler and Botox in combination with patients who are either older, or who have a much larger action caused by their lip elevators.

If you are going to treat a gummy smile with dermal filler, the patient must have signs of volume loss in the area, typically a nasolabial fold shadow which can be corrected, thus reducing the movement of the lip.

How common is it to treat gummy smiles?

Despite being a common facial characteristic in the population, it is not a particularly common treatment request amongst patients. The reasons for this are speculative, but Dr Tim suggests that it might be because people get used to having a gummy smile. Unlike other things which trigger a patient to seek aesthetic treatment, such as ageing, a gummy smile is typically something they have always had, and it becomes part of their identity; hence, many patients are not particularly concerned by it.

However, there are things which can trigger a patient to seek treatment for a gummy smile.

After having cosmetic dentistry to ‘fix’ their teeth, some people realise that they still do not have the smile that they want. Therefore, it can be appropriate to modulate the top lip, and some aesthetic dentists will do this as part of a dental consultation for smile makeovers.

For facial aesthetic clinicians, it may come up for discussion as part of a consultation for lip treatment. If you are consulting a patient properly about lip treatments, you can discover that one of the reasons why they want lip enhancement is to cover their gums by lowering their lip slightly. This can be achieved by approximately 1-2mm with a small quantity of dermal filler but otherwise will require dampening of the smile with botulinum toxin and/or dermal filler elsewhere.

What can go wrong when treating a gummy smile with Botox?

Patient selection is uniquely vital for treating gummy smiles and may not be appropriate for every patient who presents with a gummy smile.

There is a chance that you can create a beautiful result that looks great in a photograph, but which the patient and their nearest and dearest will hate because of the effect it has on changing the dynamics of their face, and their smile. If you change a patient’s smile, it changes a very important part of their communication which can sometimes make them look a little odd to those who know them well, but perhaps not to strangers. We tend to know how the faces of our friends and family members move, understanding when their reactions are authentic; but if that changes, it can create a sense of distrust or confusion, which patients must be counselled about.

Similarly, it is very easy to overtreat and create a look that some refer to as ‘The Cat in The Hat’ appearance with a very long philtrum and a strange smile that pulls upwards because of over dampening of the lip elevators.

To avoid this, you must use very low doses of botulinum toxin (approximately a two-unit Botox dose on each side to begin with) and spend time learning the dynamics of your patient’s face rather than relying on a standard, one-size-fits-all approach which is more likely to result in one of the side effects mentioned. Remember, less is more, so make small adjustments, advises Dr Tim; you can always add more botulinum toxin later, but you cannot take it out again and the patient must live with the result until it resolves naturally if you have overdone it.

Learn more about the muscle anatomy involved in treating gummy smiles with Dr Tim’s blog on the levator labii alaeque nasi muscle. For additional guidance on botulinum toxin treatments, download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin

Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.

Aesthetics Mastery Show

Gummy smile fix with BOTOX

Dr Tim says:

“Many patients will come to you wanting to fix their gummy smile. Botox is one of the easiest ways to do this, but the indications to treat and patient selection pay a big part in the success of this treatment. Plus…in this episode I also share footage of me performing a gummy smile treatment in my studio and talk you through the process.”

Watch the full Aesthetics Mastery Show here.

The show has had thousands of views already and has also generated some interesting feedback and queries.

Read the comments and join in the debate on our YouTube channel.

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BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

• BOTOX® Foundation Course
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Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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