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A beautiful smile is not only about dazzlingly white, straight teeth. An ideal smile is one in which the upper gums are either not visible at all, or only the edges of the gums (1-2 mm) are visible. If the upper gums are exposed by 3 or more millimeters during a smile, such a smile is called gummy or gingival.
A gummy smile can appear for several reasons: an overbite, a short or overactive upper lip, a high-set upper jaw, or short maxillary central incisors.
It is not entirely correct to call a gummy smile a pathology; rather, it is a cosmetic defect that does not affect the function of the teeth. If a gummy smile causes psychological discomfort to a person, it can be corrected using aesthetic cosmetology methods.
Causes of gummy smiles in children and adults
In adults, a gummy smile is quite rare, since this problem in most cases appears in childhood. There are several known main reasons for the appearance of this problem: improper development of the facial skeleton, a short upper lip that cannot cover the gum, or, on the contrary, an overly large gum that covers the upper row of teeth more than necessary. At the same time, a strongly pronounced gummy smile, as a rule, is a consequence of malocclusion, or anomalies in the development of the maxillofacial skeleton.
tip of the nose
The tip of the nose is an important component of its aesthetic appeal. With age, the tip of the nose droops, which emphasizes the convexity of its back. Drooping of the nasal tip in young patients is associated with increased activity of the depressor septum muscle during smiling, which is also often accompanied by shortening of the upper lip. The same phenomenon is observed in those with a prominent nose and an underdeveloped chin.
Before deciding on the introduction of BTA, the length of the patient's upper lip and nasolabial angle is assessed. There are 2 ways to administer injections into the depressing septum nasal muscle: percutaneous and intraoral. The latter method is quite difficult to implement, so we will only consider the method of administering BTA through the skin.
Due to the special sensitivity of the nose to external anesthetics, it is recommended to use ice compresses to reduce pain. BTA insertion points are located on both sides of the nasal septum at the base of the medial crus (Figure 12)
.
The BTA drug is administered superficially in a dosage of 1-2 units. Botox® or 4-6 units. Dysport® for every point. Dosage may vary depending on the desired degree and duration of correction, facial proportions, observed muscle activity and the work of adjacent muscles.
Figure 12. BTA injection points for correction of drooping nasal tip
Complications: In general, complications when correcting drooping nasal tip with BTA preparations are extremely rare. Among the side effects, patients most often name pain. Too much action of toxins on the depressor septum nasalis muscle can lead to ptosis of the upper lip.
Reconstructive surgery in the treatment of gummy smiles
In situations where a gummy smile appears as a result of abnormal development of the facial skeleton, the only effective solution to the problem is surgery. For these purposes, osteotomy (correction of the upper jaw) and ostectomy (operation performed to correct the lower jaw) are used.
In the vast majority of cases, such surgical interventions are carried out in the presence of serious anomalies in the development of the bite, but can also be performed in the normal position of the jaws, for example, to correct a gummy smile.
Wrinkles in the perioral area
With age, the lips undergo a number of changes, including shortening of the lateral part, enlargement of the dermal part of the upper lip, thinning of the red border and the appearance of many vertical wrinkles around the mouth. These wrinkles, also called smoker's lines, can be the result of sun exposure, smoking, hereditary factors and overactive orbicularis oris muscle, such as in musicians. There are several ways to eliminate wrinkles on the upper lip, including filler injections and various anti-aging procedures. Botulinum therapy is used to correct age-related changes in the perioral area, especially in the presence of deep static wrinkles.
Treatment of the orbicularis oris muscle with BTA preparations is carried out with extreme caution in order to achieve the effect of reducing wrinkles and not affect the normal functioning of the oral area. In addition, it is unacceptable to administer BTA near the corners of the lips. Otherwise, relaxation of the muscles that raise the corners of the lips under the influence of the toxin will lead to ptosis of the lips and drooling. Injecting BTA above the middle of the upper lip will lead to a smoothing of the cupid's bow, which is an undesirable effect from an aesthetic point of view.
In general, 1-2 injections are made into each quarter of the perioral area. To avoid dysfunction of the oral area, it is recommended to administer BTA preparations in very small doses. When the toxin is injected 5 mm from the border of the red part of the lips, the secondary aesthetic effect of a slight eversion of the lip is achieved (Figure 13)
.
Figure 13. BTA injection points for the correction of wrinkles in the perioral region
Complications: An overdose of BTA preparations will lead to dysfunctions of the lips such as the inability to fold them into a tube, difficulty pronouncing plosive consonants, and difficulty eating and drinking. For this reason, it is recommended to start botulinum therapy in the perioral area with minimal doses and repeat them as necessary.
Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:
— When performing BTA injections in the perioral area, it should be remembered that the muscles located around the lips are involved in the implementation of important physiological functions. Therefore, correction of this zone must be carried out very carefully. The orbicularis oris muscle is divided into the marginal part (pars marginalis) and the labial part (pars labialis). Injections of BTA into the labial part allow the lips to be slightly turned out, which creates the effect of increasing their area and volume. Injections into the marginal part of the orbicularis oris muscle are performed in the presence of purse-string wrinkles. Dividing the skin portion of the lip in half and retreating at least 5 mm from the columns of the philtrum and from the corners of the mouth, subcutaneous injections are usually made at 2 points on each side in a dose of 2-5 units. Dysport.
Dimple on the chin
A dimple on the chin is formed as a result of contraction of the mentalis muscle. The BTA drug is injected into one or two symmetrical points located approximately 1 cm from the line dividing the face in half directly above the protrusion of the chin. It is not allowed to insert BTA closer than 1 cm from the lower lip. Since the mentalis muscle is located deeper than the others, intramuscular injection is recommended to the periosteum, below the dimple. This will prevent the toxin from spreading into the orbicularis oris muscle. Some authors argue that, despite the deep location of the mentalis muscle, good results can be achieved with superficial injections (Figure 15)
. The recommended total dose is 2.5-8 units. Botox® or 2.5-20 units. Dysport®.
Figure 15. BTA insertion points for correction of dimpled chin
Complications: As long as the restrictions on BTA insertion near the lower lip are observed, this procedure does not entail any complications other than bruising and hematomas.
Vertical wrinkles from the corners of the lips to the chin
Deep wrinkles from the corners of the lips to the chin can give the face a dissatisfied, gloomy, and sometimes even disdainful expression. The reason for the formation of such wrinkles lies in the combination of several factors: a reduction in collagen levels, atrophy of adipose tissue, and the presence of excess or sagging skin. All these factors can be corrected with plastic surgery and filler injections. In some cases, the depth of wrinkles from the corners of the lips to the chin may increase due to increased activity of the depressor anguli oris muscles, which, when attached to the skin, can pull the corners of the mouth down. Then, by relaxing these muscles with BTA preparations, it is possible to ensure that the zygomatic major and levator anguli oris muscles return the corners of the mouth to their normal position. In some patients, the increase in the depth of wrinkles from the corners of the lips to the chin is facilitated by the activity of the platysma muscles intertwined with the depressing corners of the mouth. Then the effect of BTA drugs should be directed at both muscle groups. Sometimes the best results can be achieved by combining BTA preparations and dermal fillers, with the former enhancing and prolonging the effect of the latter.
To determine the position and feel the depressing angles of the mouth muscles and platysma, the patient is asked to make a grimace and expose a row of lower teeth. Typically, BTA is administered intramuscularly at 2 points on each side. The first of these is the depressor anguli oris muscle, and the second is the platysma cords attached to the lateral part of the orbicularis oris muscle. Insertion of BTA near the corners of the lips or the middle of the lower lip is not recommended to avoid relaxation of the orbicularis oris and depressor lower lip muscles.
The first point is easy to detect by palpation; it is usually located on the continuation of the nasolabial folds on an imaginary vertical line located at a distance of 1 cm from the corners of the lips. The second point is located slightly closer to the outer border of the lower jaw (Figure 14)
.
Figure 14. BTA injection points for the correction of vertical wrinkles from the corners of the lips to the chin.
Some authors suggest administering one BTA injection on each side at a distance of no more than 1 cm above the lower edge of the lower jaw on imaginary parallel lines drawn through the corners of the lips. The recommended starting dose is 2-5 units. Botox® or 10 units. Dysport® at each injection point and is subject to adjustment depending on the patient's muscle mass.
Complications: Too much BTA or its administration near the corners of the mouth can cause asymmetry or disturbances in the oral area, such as drooling or difficulty pronouncing certain sounds.
Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:
— The depressor anguli oris muscle is the most superficial muscle in the lower third of the face, therefore, in our experience, it is more rational to administer BTA subcutaneously: the needle is inserted into the skin at an acute angle, almost parallel to the surface. Thus, we control the depth of injection and exclude diffusion of the toxin into the underlying muscles - quadratus and depressor lower lip. In our experience, administration is 6-8 units. Dysport is enough to achieve a pronounced effect.
Gingivitis or Periodontitis
Treatment of periodontitis and gingivitis with laser is the most effective treatment method today.
The beam action very precisely and effectively cleanses periodontal pockets, achieving sterility that cannot be achieved with mechanical cleansing and rinsing. The treatment is aimed at the cause of the disease - pathogenic flora, which occurs primarily due to improper daily cleansing. Already after the first procedure, patients notice that bleeding and inflammation of the gums have decreased, and the pain during chewing has gone away.
Platysma bands
Age-related skin changes are associated with excessive laxity of the skin, loss of elasticity, formation of a double chin, lipodystrophy, prolapse of the submandibular glands and bone resorption. The subcutaneous muscle of the neck can become overactive, lose tone, or disintegrate, all of which leads to the so-called “turkey neck” effect. Platysma bundles located horizontally and vertically become noticeable with increased contraction.
Botulinum therapy in the neck area is aimed at reducing the external manifestations of platysma contraction. In addition, relaxation of the platysma bands has a positive cosmetic effect on the oval line and wrinkles from the corners of the lips to the chin. The best candidates for botulinum toxin therapy in the neck area are patients who demonstrate active contraction of the platysma during conversation.
BTA preparations are administered to the patient in a sitting position with maximum tension of the platysma in the direction of the cords. Depending on the length of the cord, the BTA is inserted into 4-8 points located at a distance of 1.5 cm from each other, grasping the cords with the non-dominant hand (Figure 16)
.
Figure 16. BTA injection points for correction of age-related changes in the neck.
The moderate initial recommended dose is 2 units. Botox® or 5 units. Dysport® for every point. Too deep administration and overdose should be avoided.
Complications: Often, after injections of BTA drugs into the neck area, bruises remain. It is recommended to avoid injecting BTA into the pharynx due to the risk of exposure of the underlying muscles to the toxin, which can lead to difficulty swallowing, weakening of the neck and dysphonia. Botulinum therapy is also not suitable for correcting horizontal wrinkles on the neck. In addition, due to the large number of injection points for BTA drugs, the anti-aging neck correction procedure is quite expensive.
Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:
— To date, some experience has been accumulated and there are published data on botulinum therapy for horizontal neck wrinkles. Correction of this area, of course, requires a combination of botulinum therapy and injection plastic surgery using the most flexible and easily sculpted fillers. BTA injections as monotherapy are not always effective. The total dose of Dysport for the correction of neck wrinkles is 50-60 units. Botulinum toxin is injected along the wrinkle at points located 5 mm above it, at intervals of approximately 1 cm. As a rule, the drug in standard dilution is additionally diluted 2 times with saline solution.
