With Mario Polo, DMD, MS
OP: How did you get interested in using Botox® to treat gummy smiles?
Polo: I was frustrated at not being able to offer these people, those with hyperfunctional upper-lip elevator muscles, any treatment whatsoever. It was while I was working with plastic surgeons who were using botulinum toxin Type A, better known as Botox, for other cosmetic purposes, that I got the idea that it could be used for this problem.
OP: How much research did you do before you used the technique?
Polo: I did extensive research in anatomy, physiology, and immunology. I learned that the movement of the upper lip is controlled by several muscles that originate in the midface area. Some of these muscles control upward—that is, elevator—movement, and some control horizontal movement. In people with this type of excessive gingival exposure, the elevator muscles are too strong—they’re hypertonic, so they pull the lip too far up when smiling. Since Botox weakens and relaxes the muscles that produce contractions, it seemed logical to use it for this problem.
OP: How do you determine dosage?
Polo: Through experimentation in three phases of my first study with five patients, I determined that the correct dosage for patients with moderate to severe cases is 2.5 units per 0.1 cc solution injected at a maximum of four sites. This dosage is appropriate for those with more than 3 mm of gingival exposure. What varies is the number of injection sites: two sites for patients with 3 to 5 mm exposure, four sites for those with more than 5 mm exposure. If there is less than 3 mm exposure, I do not recommend Botox, as the results may not be satisfactory and there is a danger of overcorrection.
OP: Can you describe the injection process? How long did it take to master it?
Polo: It took a good two and a half years of education and training to master the entire procedure. Injections are administered with a tuberculin syringe to sites on the face that have been carefully chosen based on a study of the patient’s facial anatomy. Facial symmetry and asymmetry are very important. The patient needs to have a neuromuscular imbalance to be eligible for Botox. The examination is very important. For instance, you need to determine whether there is a greater pull on one side of the face or the other, so you know how to distribute the injections.
OP: How many patients have you treated?
Polo: I’ve administered more than 500 injections since beginning the treatments in the year 2001.
OP: What percentage of treatments have you considered successful?
Polo: There is a satisfaction rate of 95% among my patients, but I consider the treatments 100% successful, since there is improvement in every case. My second investigation involving 30 patients was evaluated by a team of 12 physicians and received a P of less than 0.0001, which is an extremely high statistical level of success. Among my clientele are models and beauty queens, including Miss Universe of 2001 and 2006. Some of them have benefitted from Botox. You can see examples of results at my Web site at www.mariopolo.com.
OP: What are the side effects?
Polo: Side effects of a properly performed procedure are minimal, limited to minor discomfort and slight bruising at the injection site, just as it would be with any injection. There is, however, a danger from overdosage, as too much Botox could result in paralysis of the targeted muscles. The properly measured dosage is critical to a successful outcome.
OP: How often do patients need to return for additional injections?
Polo: The effect lasts about 6 months, with a range of 4 to 8 months, at which time the patient can return to repeat the process. It’s important not to give injections prematurely (before the effects of the treatment have worn off), as this can result in a buildup of antibodies to Botox that would dilute the effect of further treatments.
OP: What advice do you have for other orthodontists considering adding Botox to their practice?
Polo: They should be sure to take the required training and educate themselves in related areas such as anatomy. They should also check into the laws in their state: In some states, it is not yet permissible for dentists to administer Botox. It’s also important to be aware that Botox is not for pregnant women or those with allergies to Botox or albumin. Additionally, those with debilitating muscular diseases such as MS or ALS should not be given Botox.
- Before: Two patients present with gummy smiles.
- After: Following Botox, both patients show a marked decrease in gingival display.
Mario Polo, DMD, MS, is in private practice in San Juan, Puerto Rico. He is a diplomate of the ABO and a past president of the MASO. He lectures extensively on his work and can be reached at