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Dr. Barry Eppley

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Archive for the ‘gummy smile surgery’ Category

Botox for the Gummy Smile

Thursday, September 6th, 2012


While a smile is a critical human expression that exposes one’s pearly whites, too much tooth and gum show is deemed undesireable. Known as a gummy smile, it is technically defined as any gum show that exceeds more than 2mms above the tooth line when smiling. While that is a good quantitative measurement of it, many people with that amount of gum show are not bothered by it. When the amount of gum show when smiling exceeds 5mms or more, almost everyone is bothered by it.

When one has excessive gum show it appears that one has a longer face. Often times this is true and some degree of vertical maxillary bony excess exists. But the amount of vertical maxillary excess may not be significant enough or the patient may not want to go through a maxillary impaction osteotomy to make the formal correction.

Alternative soft tissue strategies for treatment of the gummy smile is directed towards either lengthening the upper lip, decreasing the upward muscle pull of the smile muscles or a combination of both. I have successfully used the surgical approach of a V-Y mucosal advancement, transaction of the levator  superior labii elevator muscles and a shortening vestibuloplasty to lessen the amount that the upper lip elevates which then decreases the amount of gum exposure seen. Even though this approach works, and is a fairly easy surgery to undergo, not every gummy smile patient wants to have surgery to treat it.

In the September 2012 issue of Plastic and Reconstructive Surgery, an article was published on ‘A Simplified Method for Smile Enhancement: Botulinum Toxin Injection for Gummy Smile’. In a non-surgical method, Botox injections were placed into the levator labii superior nasalis muscle using 2 to 4 units per side. Over a 15 month period, 52 patients (smiles) with excessive gum show were treated. The outcomes of the injections were evaluated by photographs and questionnaires. Average patient satisfaction on a 10 point scale was 9.75. In all patients, the positive effects of the injections (decreased gummy smile) persisted for 3 or more months.

Having used this injection technique myself, the sheer simplicity of this approach makes it the first treatment that a gummy smile patient should have.  At just 4 to 5 units per treatment, this makes its $100 price tag (or less) very affordable. That is roughly 1/3 the cost of treatment of the glabellar furrows (the most commonly done facial Botox treatment) to improve an aesthetic problem which is equally distracting. Even though its effects last the usual Botox time of 3 to 4 months, two quick injections on each side of the nose restores the smile improvement.

My recommendation for gummy smile patients is to give Botox a try and judge the benefits themselves. If eventually they want to move to a more permanent and profound correction then a soft tissue surgery approach can be done.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Soft Tissue Correction Of The Gummy Smile

Sunday, July 17th, 2011

Background:  The gummy smile is when excessive soft tissue (attached gingiva) is shown during upper lip animation. Ideally, when more than 1mm of gingival shows it is deemed aesthetically excessive although it probably is only bothersome to most people when it is more than 2 or 3mms. The cause of almost all gummy smiles is vertical maxillary excess, the maxilla is too vertically long for the amount of lip tissue.  

In many gummy smile patients, the maxilla is not long enough to justify a LeFort I or maxillary impaction. Only when the amount of gingival show exceeds more than about 7mms can bone shortening be worth the effort. This leaves a large number of patients to seek out a potential soft tissue or upper lip lengthening approach.

Lengthening the upper lip is a lot more difficult to achieve than shortening it. The upper lip is a suspended structure but the effects of smiling and scar contracture work against any lengthening effort. This requires that all factors that contribute to the upper lip anatomy must be managed during any upper lip lengthening effort.   

Case Study: This 23 year-old female had long been bothered by how much gum she showed when smiling. She had a very broad smile width and the upper lip pulled high up against the face of the maxilla. At maximum smile, the amount of exposed gingival was 9mms. She had an excellent Class I occlusion so the thought of vertical maxillary shortening was understandable not acceptable. The expectation with any soft tissue lengthening procedure was to decrease the amount of gummy smile by half.

Under local anesthesia (infraorbital nerve blocks) supplemented with some IV sedation, a large v-shaped mucosal flap was incised and raised on the inside of the upper lip. One of the levator muscles of the upper lip (quadratus superior nasi) was transected across the base of the nose with this exposure on each side. The v-shaped flap was then advanced and closed in a V-Y pattern to create internal lengthening and increased vermilion fullness. An excision of upper lip mucosa and mucoperiosteum on the face of the maxilla was then done to create a vestibular shortening effect as well.

At six weeks after surgery, all upper lip swelling was gone and the patient had a stable result. She had achieved a 7mm reduction in exposed gingiva with unrestricted and natural movement of the upper lip.

The best result for soft tissue correction of the gummy smile addresses three parts of the upper lip anatomy. The internal mucosa of the upper lip is increased with a V-Y flap. The central upper lip elevator muscle is transected to partially deanimate upper lip movement. The depth of the upper lip vestibule is shortened to help resist upward scar contracture.

Case Highlights:

1) Soft tissue correction of the gummy smile can be done when the maxilla is not excessively long as demonstrated by lip competence at rest. The gummy smile is apparent with smiling.

2) Upper lip lengthening can be accomplished by a V-Y mucosal advancement, levator muscle transection and vestibular shortening.

3) Some relapse should be expected after surgery which stabilizes by six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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