READERS’ FORUM
Letters to the editor*
Botox injections for gummy smiles
I want to comment on the recent article, “Botulinum toxin
type A (Botox) for the neuromuscular correction of excessive
gingival display on smiling (gummy smile)” (Am J Orthod
Dentofacial Orthop 2008;133:195-203), by Mario Polo.
This is the most comprehensive and scientifically based
article that I have seen on smile esthetics related to gingival
display in the literature, orthodontic or otherwise. This author
expanded on previous studies and illustrated with a respect-
able cohort of qualified patients with significant scientific
parameters. There is no doubt that the goals of this study were
met and that the author successfully proved that treatment of
“gummy smiles” with Botox produced consistent, statistically
significant, and esthetically pleasing results.
I would like to comment on—not criticize—several
aspects of this study based on personal experience and
observations. I have performed similar treatments for this
condition for the past decade and have experimented with
various injection sites to obtain results similar to Dr Polo’s.
Although I believe similar results can be obtained with
alternate injection sequences, the injection sites and dosages
described in this article make sense in the physiology of
dynamic perioral muscular contraction and subsequent weak-
ening. Although I have before and after pictures that show the
same results as Dr Polo’s, I believe there is a lot more than
what meets the eye in a still picture. Almost without excep-
tion, the patients I treated ended up with less gingival
exposure, but they also experienced unesthetic perioral ani-
mation. More simply stated, the patients had more pleasing
smiles in the after pictures than in the before, with less
exposed gingiva, but, when observing them in normal, every-
day oral function, they looked dysfunctional. This varied
from slight changes in smile, pucker, and word pronunciation
to a “stroke-like” expression in some phases of animation.
Obviously, one could say that these patients were simply
overtreated, but my experience with botulinum toxin A is
extensive,1-5 and the observations were made after my learn-
ing curve with this procedure. One possible reason for my
perceived differences from Dr Polo’s experience might have
something to do with the ages of the patients. In Dr Polo’s
study, most patients were younger, orthodontic-aged subjects.
My patients are mostly 35- to 60-year-olds who want cos-
metic enhancement. It is possible that adolescents and teens
are less cosmetically inclined or picky than mature adults.
The younger subjects might also tolerate concomitant dys-
function more readily than adults, who are subject to more
social scrutiny of varying degrees among their more percep-
tive peers. In many of my patients, the trade-off for showing
less gingiva was not worth the “funny-looking” smile, pucker,
and related oral function. My ratio of patients seeking
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
782
repeated treatment by this method has been low. One could
say that the problem lies in my treatment, but, again, I believe
my techniques are consistent with the standard of care for this
procedure.
An additional fault of this well-designed study method
(which was not in Dr Polo’s control) was the apparent fact
that the patients knew what the treatment goal was: less
gingival exposure when smiling. A smile, especially a spon-
taneous one for staged photography, is extremely difficult, if
not impossible, to replicate. There are so many subjective
influences on the posed smile. Showing a maximum smile
evokes many more muscles than those of the perioral region.
You will see muscles in the lower face (mentalis) activated,
and sometimes even in the upper face at maximum elicited
smile. In the upper face, an extreme smile often produces a
squint with a noticeable decrease in the palpebral fissure
(distance between the open eyelids). Because the patients
know that the treatment is designed to produce a different
smile, I believe they could have an unconscious (or a
conscious) tendency to smile differently in the after photos.
This phenomenon besets all investigators and is a variable
that cannot be controlled. I think this might be illustrated in
some of the before and after images of Dr Polo’s subjects in
Figure 4 (and especially Figure 9) of the article. Six of the 12
subjects are obviously recruiting upper facial muscular anat-
omy (squinting) in the preinjection photos but not in the
postinjection pictures— evidenced by the lack of squint in the
after pictures and the increased palpebral fissure. Although
Botox injected in the upper lip region might affect the lower
lid orbicularis in a small way, the effect will not cause
changes in the remote region of the lateral or superior
orbicularis musculature. I believe these patients were merely
producing a more profound smile in the before pictures than
in the after images. This does not detract from Dr Polo’s
findings about these smiles, which I believe are more esthetic.
Bottom line: a really big smile might be accompanied with a
squint, whereas a medium smile is not. It is the difference
between a full face smile and a “lips only” smile (as seen on
flight attendants when deplaning). Botox in the lip will not
change the upper facial influence on smile, and thus at least
half of these pictured patients were smiling harder in the
before images. Again, this is by no means critical of Dr Polo
because it is a reality of anyone taking before and after
clinical photos.6-12 In my thinking, the only reliable means of
controlling smile dynamics would be to accurately stimulate
the individual muscles with electrical current (before and
after treatment) with needle electrodes; this would result in
controlled, precise, and repeatable contractions. Obviously,
this would be a painful situation and almost impossible to
duplicate in an awake, conscious patient in the upright
position. Such are the variables imposed by the beautifully
intricate facial mimetic muscles.
I think this is one of the most comprehensive studies to
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
date and will be cited for years to come. My comments are to
relate personal experience from a large Botox practice and
elucidate variables that influence studies of this nature. I think
Dr Polo proved that a hyperdynamic smile can be treated with
Botox. Each practitioner must determine whether the pluses
and minuses of this treatment are applicable in his or her
practice.
Finally, I want to add a note of caution for practitioners
who read this article and think that changing a smile with
several simple cutaneous injections of Botox can be done
without complications. Although Botox treatment in the
upper face produces dramatic results with minimal complica-
tions, Botox injection in the mid and lower face can be hugely
problematic in inexperienced hands. A small amount of this
extremely potent toxin in the wrong place can produce a
horrific dysfunction that can last for 3 to 4 months. I have
seen patients from other offices with severe drooling, inability
to pucker, grossly asymmetric smile, inability to annunciate
certain words or sounds, and “stroke-like” animation because
of misplacement or overdosage of Botox. In the upper face,
complications can include double vision and eyelid droop; in
the midface, complications can include dysanimation; and, in
the lower face and neck, there can be problems in speaking,
swallowing, and holding the head up. Having said this, no
practitioner should inject this potent neurotoxin without
proper training and the ability to manage possible related
complications.
Joe Niamtu, III
Richmond, Va
Am J Orthod Dentofacial Orthop 2008;133:782-3
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.04.007
REFERENCES
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surgery. Selected Readings in Oral and Maxillofacial Surgery
2004;12:1-22.
3. Niamtu J 3rd. Botulinum toxin A: a review of 1,085 oral and
maxillofacial patient treatments. J Oral Maxillofac Surg 2003;
61:317-24.
4. Niamtu J 3rd. The use of botulinum toxin in cosmetic facial
surgery. In: Niamutu J, editor. Cosmetic facial surgery oral and
maxillofacial surgery clinics of North America. Philadelphia:
W. B. Saunders; 2000. p. 595-612.
5. Niamtu J 3rd. Aesthetic uses of botulinum toxin A. J Oral
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6. Niamtu J 3rd. Clinical photography. In: Irwin T, Terberg T,
editors. Perfect medical presentations. London: Churchill &
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7. Niamtu J 3rd. Saving and archiving images. In: Irwin T, Terberg
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Author’s response
During the last decade, I have focused my energy, time,
and effort on producing the best esthetic results for persons
with excessive gingival display on smiling, through Botox
injections. I honestly wish for these patients to smile and
laugh without restriction; during preinjection consultations
and evaluations, I hear them talk about the psychological
impact and low self-esteem this condition has on them.
Many of my patients are happy with the results of Botox
injections and return for reinjections. Some patients do not
return, or do not return every 6 months, for financial rea-
sons—a phenomenon observed not only for patients treated
for gummy smiles, but also for other cosmetic reasons,
worldwide.
Dr Niamtu referred several times to photographs but did
not mention videos, which show a subject’s smile in a
dynamic, animated state. Since each video clip lasts for 20
seconds, it can project a more reliable “picture” of the smile.
In the videos, you can truly evaluate “pucker,” “stroke-like,”
“funny-looking,” “grossly asymmetric,” or “dysfunctional”
smiles. As I mentioned in my AJO-DO article, the videos of
my patients can be seen at http://www.mariopolo.com/html/
botox_gallery.html (click the video link).
Regarding how smiles were elicited during the study, at
no time during any before or after photo or video session was
an attempt made to manipulate the subjects to control or pose
their smiles. I tried hard to have all subjects smile as equally
and unrestrictedly as possible in both before and after
photographic sessions.
I stand firm on my theory of the effect of Botox injection on
muscles in the periocular region and its relationship with
squinting, mostly the levator labii superioris and the zygomaticus
minor muscles. For the record, none of the patients I injected for
this purpose have had any drooling, inability to pucker, grossly
asymmetric smiles (or asymmetric smiles in any degree), inabil-
ity to enunciate words or sounds, or “stroke-like” animation after
receiving Botox injections in my office.
Many questions come to my mind regarding differences
between Dr Niamtu’s experience and mine. Are we injecting
the same sites, or are there small differences? Are you
injecting the orbicularis oris? Are you injecting the midpor-
tion of the bellies of the muscles or their superior or inferior
portions? Are we using exactly the same dosage? Are we
compensating the same way for individual factors, such as
smile asymmetry, cant of the maxillary plane, facial soft-
tissue laxity, and so on? Are we calculating in the same way
the units injected and the total number of sites injected