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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘gummy smile’

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

Plastic Surgery Correction of the Gummy Smile

Tuesday, March 3rd, 2009

In the ideal smile, the upper lip sits just at or above the top of the teeth. The general rule is that 1 to 2 millimeters of gum exposure with a maximal smile is aesthetically acceptable. When some people smile, however, a large gap becomes exposed between the lip and the upper teeth, exposing a lot of gum tissue and producing the so-called gummy smile. The gummy smile can be due to a variety of factors including a hyperactive muscle which lifts the upper lip too much, a thin upper lip which rolls under when smiling, gum tissue which covers too much of the upper teeth, and a long upper jaw. Careful examination of the smile, at rest and when smiling, can help identify which one(s) of these factors is contributing to the gummy smile problem.

The classic minimally invasive treatment is the excision of gum tissue also referred to as a gingivoplasty. The gingivoplasty is the removing of excess gum tissue from the top part of the teeth, making the tooth look longer and lessening the amount of gum tissue exposed between the lip and the teeth, One must be careful to not remove too much gum tissue which can expose the root portion of the tooth leading to chronic sensitivity. Occasionally dentalveneers can be used as part of this procedure to help increase the amount of tooth show.

Other minimally invasive procedures include the injectable treatments of  Botox® and off-the-shelf fillers. Injecting Botox into the hyperactive muscles of the upper lip will reduce how much the upper lip moves upward resulting in less of a gummy smile. Like all Botox injections, however, the result will last at best for four months. But it can be tremendously useful in someone who has a big wide smile movement. If the upper lip is also thin, injectable fillers such as Juvaderm or Perlane can be added to help bring down the vermilion border (lower edge of the upper lip) slightly. These injectable fillers will last longer than Botox, lasting up to six to months. In a few cases, I have done both at the same time which overall creates a better effect than either one alone.

Another option to reduce a ‘high lip line’ is an upper lip lowering procedure. This minor operation was initially introduced in the 1970s but has only recently become more popular. It is done with a local anesthetic and involves the re-attachment of the gum tissue under the lip (this does not involve any surgery on the lip that you see) at a level that is closer to the teeth. This results in not only lowering the lip line at rest but also limiting how much it moves upward when smiling. This procedure shortens the depth of the vestibule (space between the upper lip and gum tissue high up under the lip) to help bring the lip down somewhat. This vestibuloplasty can also be combined with a V-Y mucosal lip lengthening which can bring down the position of the upper lip a few more millimeters.

In severe gummy smile cases, the problem is skeletal in nature with a long face syndrome. The upper jaw has simply grown down too much. In so doing, it carries the teeth way below the upper lip and a lot of gum tissue can be seen, often up to 5 to 8 millimeters too much. These patients also have difficulty in putting their lips together with a pseudo short upper lip appearance. Correction requires upper jaw surgery (LeFort I impaction) to remove a wedge of upper jaw bone and allow the visible tooth part of the upper jaw to ‘go back up under the upper lip’.

The proper treatment of the gummy smile is based on a good evaluation to determine what anatomic problems is making it look so. Minor cosmetic changes can be done with gingivoplasty, injectable treatments, or a lip lowering procedure. Correction of large gummy smile requires maxillary bone shortening 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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