CASE REPORT

Nonsurgical treatment of skeletal

maxillary protrusion with gummy smile
using headgear for growth control,
mini-implants as anchorage for maxillary
incisor intrusion, and premolar
extractions for incisor retraction
Armando Yukio Saga,a Eusta
quio Afonso Arau

jo,b Oscar Mario Antelo,a Thiago Martins Meira,a
a
and Orlando Motohiro Tanaka
Curitiba, Brazil, and St. Louis, Mo

An adolescent girl, aged 12 years 11 months, was evaluated for orthodontic treatment. Her chief complaints
included a difficulty with keeping her lips passively closed and excessive gingival exposure upon smiling. Her
treatment plan included (1) restriction of maxillary growth with cervical headgear, (2) extraction of the maxillary
first premolars to reduce the maxillary protrusion and the mandibular second premolars to facilitate Class II
dental correction, and (3) management of maxillary incisor intrusion via anchoring with mini-implants. When indi-
cated, even in the absence of large space discrepancies, extractions can be beneficial to the patient. The final
results showed an attractive smile, passive lip seal, and a more esthetic and balanced facial profile. Retention
records confirmed the stability of the treatment. The 5-year follow-up visit revealed that the treatment results
were quite stable. (Am J Orthod Dentofacial Orthop 2020;157:245-58)

T
he degree of perceived improvement of facial es- orthodontic treatment to improve their facial appearance
thetics is closely related to a patient's approval and consequently their self-esteem and quality of life.2
and satisfaction of the completed orthodontic The smile is also an element of significant importance
treatment. Therefore, current orthodontic treatments in facial esthetics and commonly becomes one of the main
put a major focus on improving facial balance because aspects considered in a patient's evaluation of how suc-
it is one of the leading reasons for which patients seek cessful their orthodontic treatment was.3,4 The amount
treatment.1 An increased facial convexity caused by of gingival exposure at smiling influences attractiveness,
maxillary anterior teeth protrusion resulting in upper and both lay people and dentists consider enlarged
lip projection associated with a retruded mandible is a gingival display to be an unpleasant esthetic feature.5,6
common characteristic of orthodontic patients with a The objective of this case report was to present the
skeletal Class II pattern and is considered to be estheti- orthodontic treatment of an adolescent patient with
cally unpleasant. Frequently, these patients request skeletal Class II gummy smile (GS) and lip incompetence.
The reasoning for tooth extraction and the orthodontic
mechanics are explained in detail.
a
School of Life Sciences, Pontifical Catholic University of Paran
a, Curitiba, Brazil. DIAGNOSIS AND ETIOLOGY
b
Center for Advanced Dental Education, Saint Louis University, St. Louis, Mo.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- The patient, an adolescent female aged 12 years
tential Conflicts of Interest, and none were reported. 11 months, presented for orthodontic treatment. Her
Address correspondence to: Orlando Motohiro Tanaka, Graduate Dentistry Pro-
gram in Orthodontics, PUCPR, R. Imaculada Conceiç~ao, 1155, Curitiba 80215 chief complaints were the existence of a difficulty in
901, Brazil; e-mail, [email protected]. keeping her lips passively closed and the presence of
Submitted, June 2018; revised and accepted, August 2018. excessive gingival exposure upon smiling (Fig 1).
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved. Facially, she presented with a symmetrical face
https://doi.org/10.1016/j.ajodo.2018.09.021 including balanced and proportional facial thirds, an
245
246 Saga et al

increased chin-lip groove with lower lip eversion, lip 6. Achieve proper overbite and overjet
incompetence with forced sealing, and excessive 7. Reduce the mandibular incisor protrusion
gingival display on smile (4.5 mm). During the dental ex- 8. Attempt to establish a predominantly nasal respira-
amination, a Class II, Division 1 malocclusion, exagger- tory pattern and control of allergic rhinitis
ated curve of Spee, a deep overbite (impinging
mandibular incisors), noncoincident dental midline lines
with the lower being deviated 2 mm to the left, and no TREATMENT PLAN
significant tooth size–arch length discrepancy in the
The following treatment plan was developed:
maxillary or mandibular arches were observed. In addi-
tion, an increased overjet (7 mm) was seen (Figs 1 and 1. Perform leveling and aligning of the maxillary and
2). Cephalometrically, a convex face profile (Z angle: mandibular dental arches
59.5
), protruding upper and lower lips (upper lip S 2. Manage the maxillary molars' anteroposterior con-
line: 6 mm and lower lip S line: 7 mm), acute nasolabial trol and growth response with cervical headgear.
angle (77
), dentoalveolar extrusion (U1 stomium: Owing to the patient's age, some facial growth
12 mm), and a short upper lip (length: 17 mm) were was expected. The headgear may assist with the
seen (Fig 3; Table I). The patient also presented with a skeletal Class II correction.
skeletal Class II (ANB: 12.5
and Wits: 9.5 mm) appear- 3. Extractions of the maxillary first premolars and
ance because of maxillary protrusion (SNA: 94
), with mandibular second premolars to provide spaces
the mandible well positioned relative to the cranium for retraction of the incisors and as an adjunct to
base (SNB: 81.5
), a mesocephalic pattern (SN-GoGn: the correction of the Class II dental relationship.
31
and FMA: 29
), the mandibular incisors proclined 4. Address intrusion of the maxillary incisors and cor-
and protruded in relation to the NB line (L1.NB: 38.5
rect the everted lower lip using mini-implants
and L1-NB: 10.5 mm) and also proclined in relation to 5. Refer the patient to the otorhinolaryngologist for an
the apical base (IMPA: 102
), and retroclined and ret- evaluation of the airway and attempt to establish a
ruded maxillary central incisors (U1.NA: 5.5
and U1- predominantly nasal respiratory pattern
NA: 0.5 mm) (Fig 3; Table II). The patient showed no 6. Refer the patient to the allergist for evaluation of
signs or symptoms of temporomandibular disorder, her allergic rhinitis
normal mouth opening extension without deviations
Notably, one identified limitation of the treatment
during opening or closing, hyperactivity of the elevator
plan was that orthopedic and orthodontic correction
muscles of the upper lip, and healthy periodontal tissues
would be dependent on the collaboration, compliance,
(Fig 1).
and proper use of the cervical headgear.
After panoramic radiography, no major abnormal-
ities or pathologies were detected. The third molars
were present and in the root formation stage (Fig 3). TREATMENT ALTERNATIVES
The respiratory pattern was predominantly buccal, As part of the treatment plan design stage, the
and she had allergic rhinitis, according to her mother. following other options were also considered: (1) treat-
Menarche had not yet occurred. The cervical vertebral ment without extraction, correcting the Class II relation-
maturation evaluation indicated the patient was at ship by the orthopedic and orthodontic effect of the
the CS3 stage (Fig 3).7 extraoral appliance and (2) extraction of the maxillary
and mandibular first premolars.
TREATMENT OBJECTIVES The first suggestion was disregarded because it
Based on observations of the patient, the following would not consider the retraction of the mandibular in-
items for inclusion in the treatment plan were identified: cisors, and substantial changes in the facial profile may
not occur. In addition, the second was decided against
1. Increase the nasolabial angle, correct the lower lip because the skeletal discrepancy was large, and the
eversion, and reduce the upper and lower lip protru- correction of its totality was not expected; the extraction
sion to improve the facial profile of mandibular second premolars would assist in the me-
2. Obtain a passive labial seal chanical control to compensate the Class II relationship.
3. Improve the smile esthetics, including reducing the
gingival display on smile
4. Minimize as much as possible the anteroposterior TREATMENT PROGRESS
skeletal discrepancy At the start of the treatment, all maxillary and
5. Correct the Class II, Division 1 malocclusion mandibular erupted teeth were bonded with 22-mil

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Saga et al 247

Fig 1. Pretreatment photographs.

Fig 2. Pretreatment dental casts.

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248 Saga et al

Table I. Soft tissue, profile, and esthetic measure-

ments
Pretreatment Posttreatment Difference

Variables Norm (T1) (T2) (T1T2)

Upper 0 mm 6 1 –5
lip-S line
Lower 0 mm 7 –1 –8
lip-S line
Z angle 75
59.5 75 115.5
Nasolabial 102
6 8
77 95 18
angle
Upper lip 12 mm 14 15 1
thickness
Lower lip 11 mm 13 11 –2
thickness
Gingival \3 mm 4.5 0 –4.5
display
U1-stomium 2-4.5 mm* 12 4 –8
1-3.0 mmy
Upper lip 20 mm* 17 21 4
length
24 mmy

*Denotes female; yDenotes male.

steel archwire with an 8 3 4-cm helical loop located

distally to the canines. The helical loops were acti-
vated to retract the mandibular incisors, tying-back
to the first molars. Effective tipbacks of 20
-30

Fig 3. Pretreatment panoramic and cephalometric radio- were applied distally to the first premolars to prevent
graph with the SN 7
perpendicular reference line.
mesial tipping of the first molars. Toe-in bends were
also implemented to avoid mesial rotation of the first
standard edgewise metallic brackets, except for the molars (Fig 4).
mandibular second molars. Then, the first molars After maxillary canine total retraction and mandib-
were banded. Cervical headgear with 300 gram force ular second premolar space closure, in the maxillary
per each side was adapted, and a use of a minimum arch, 19 3 25-mil stainless steel archwire with 9 3 3-
of 16 hours per day was recommended. The patient cm key loops distal to the lateral incisors and active labial
was subsequently referred to her general dentist for torque were applied to retract the incisors. Gable bends
extraction of the maxillary first premolars and were also used to obtain root parallelism in the space
mandibular second premolars. The archwires pro- closure. To assist in the correction of the deepbite,
gressed from 16-mil nickel titanium to 16 3 22-mil mini-implants were installed between the lateral and
stainless steel and 18 3 25-mil stainless steel to align central incisor roots, and elastic forces of 40 gram force
and level all teeth. in each side were implemented to intrude the incisors. In
After the alignment phase, sliding jigs were used the mandibular arch, the second molars were bonded
to retract the maxillary canines. The sliding jigs and aligned (Fig 5).
were constructed with 21 3 25-mil stainless steel The inclusion of the second molars was necessary to
archwire with hooks located at the height as near as increase the leveling of the curve of Spee; furthermore,
possible to the center of resistance of the canines. there was also a possibility that it would help in the
The direction of the elastic retraction force prevented correction of the exaggerated overbite. Figure 5 shows
the tendency of deepening of the bite because it the progress of space closure in the maxillary arch, over-
avoided the distal inclination of the canines. The bite correction, and erupting mandibular third molars.
spaces between the mandibular first premolars and The finishes of maxillary space closure, Class II, and
first molars were closed with a 19 3 25-mil stainless deep overbite corrections are displayed in Figure 6.

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Saga et al 249

Table II. Cephalometric measurements

Pretreatment Posttreatment Difference

Pattern Variable Norm (T1) (T2) (T1T2)

Skeletal pattern SNA 82
94 87 7
SNB 80
81.5 81 0.5
ANB 2
12.5 6 6.5
Wits 0 6 2 mm* 9.5 5 4.5
1 6 2 mmy
SN-GoGn 32
31 29 2
FMA 25
29 24 5
Pog-NB - 0 2 2
Dental pattern IMPA 90
102 94 8
U1.NA 22
5.5 9.5 4
U1-NA 4 mm 0.5 0 0.5
L1.NB 25
38.5 25 13.5
L1-NB 4 mm 10.5 4 6.5
U1.L1 130
123.5 140 116.5

*Denotes female; yDenotes male.

Fig 4. Retraction of the maxillary canines and space closure of the mandibular second premolar.

Further finishing and detailing were performed using Subsequently, the appliances were removed, a maxil-
19 3 25-mil stainless steel archwires in both arches (Fig lary wraparound removable retainer was placed, and a
6). Vertical elastics for intercuspation were also applied. mandibular lingual wire retainer was bonded from

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250 Saga et al

Fig 5. Maxillary incisor intrusion and retraction and alignment of the mandibular second molars.

canine to canine. To prevent a space between the gingival exposure on smile during (A) pretreatment,
mandibular first premolars and first molars from open- (B) in the middle of the treatment, and (C) at the post-
ing, fixed retentions were also bonded (Fig 7). treatment phase.
The good adherence of the patient to the use of the
headgear allowed for adequate control of the anteropos-
TREATMENT RESULTS terior growth of the maxilla (SNA from 94
to 87
); how-
After various procedures, the objectives of the treat- ever, as predicted in the treatment plan, the skeletal
ment were reached, and the patient reported satisfaction discrepancy was not corrected in its totality. The skeletal
with the obtained results. Retraction and intrusion of the discrepancy was reduced according to ANB from 12.5

incisors and control of maxilla growth resulted in im- to 6
and, according to Wits, from 9.5 mm to 5 mm.
provements in the positioning of the upper and lower The mandibular plane inclination was reduced, even
lips and in the dental and skeletal anteroposterior rela- with the use of cervical traction headgear (SN-GoGn
tionships, overbite, and inclinations of the incisors. All from 31
to 29
and FMA from 29
to 24
). The combi-
of these changes contributed to a more esthetic and nation of counterclockwise rotation and growth of the
balanced face profile. After treatment, the patient pre- mandible assisted in Class II relationship correction
sented with passive lip seal, coincidence of the median and increased the Pog-NB quantity (from 0 mm to
dental lines to the facial median line, and a pleasant 2 mm). The maxillary incisors were retained in the
smile with an absence of buccal corridors or excessive same linear anteroposterior position in relation to the
gingival display (Figs 7 and 8). Figure 9 illustrates the NA reference line, and just the inclinations were partially

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Saga et al 251

Fig 6. Completion of maxillary incisor intrusion and retraction and overbite correction and finishing and
detailing with 19 3 25-mil stainless steel archwires.

corrected as a compensation of skeletal discrepancy 13 mm to 11 mm (Table I). The gingival display on smil-
(U1.NA from 5.5
to 9.5
). The mandibular incisors ing (from 4.5 mm to 0 mm) (Fig 9) and maxillary incisors
were uprighted (IMPA from 102
to 94
and L1.NB display in relaxed posture (from 12 mm to 4 mm) were
from to 38.5
to 25
) and retracted (L1-NB from lessened by control of the maxillary vertical growth,
10.5 mm to 4 mm). As a result of changes to the incisors, maxillary incisor intrusion (1.7 mm), and increase of
the inclination interincisal angle was increased from the upper lip length (from 17 mm to 21 mm). Moreover,
123.5
to 140
(Fig 10; Table II). the retraction of the incisors and the decrease in the
The growth of the pogonium (4 mm) and the nose elevation of the upper lip on smiling possibly contrib-
(3 mm) (Table III) with retraction of the incisors ap- uted to the GS correction. No gingivectomy was per-
proached the measurements of anteroposterior posi- formed (Table I).
tioning of the upper and lower lips to normal values To evaluate the labial responses to incisor retraction,
(from 6 mm to 1 mm and from 7 mm to 1 mm, respec- measurements were performed similar to those used by
tively) and corrected the convexity of the facial profile (Z Rathod et al,8 as follows: 2 reference lines were drawn,
angle from 59.5
to 75
). The posterior repositioning of specifically (1) a horizontal line from the nasion at an
the upper lip also contributed to an improvement of the angle parallel to the sella-nasion line minus 7
(SN:
nasolabial angle to within ideal values (from 77
to 95
). 7
) and (2) a vertical line perpendicular to the first
The upper lip thickness was increased from 14 mm to one passing through the sella (SN: 7
perp) (Fig 3). Dis-
15 mm, which does not necessarily mean protrusion, tances from SN 7
perp to U1 (maxillary central incisor
whereas the lower lip thickness was reduced from tip), L1 (mandibular incisor tip), Ls (labrale superius), Li

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252 Saga et al

Fig 7. Posttreatment photographs.

Fig 8. Posttreatment dental casts.

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Saga et al 253

Fig 9. Progress of the gingival exposure correction: A, during pretreatment; B, in the middle of the
treatment; and C, at the posttreatment phase.

Table III. Landmarks distance to the SN –7
perpen-

dicular
Pretreatment Posttreatment Difference

Variables (T1) (T2) (T1T2)

SN –7
78 70 8
perp to U1
SN –7
73 67 6
perp to L1
SN –7
perp to 91 85 6
upper lip
SN –7
perp to 86 82 4
lower lip
SN –7
perp to Prn 94 97 3
SN –7
perp to Pog’ 74 78 4
Note. Variable distances are in mm.

The maxillary incisors were retracted by 8 mm, whereas

the mandibular incisors were retracted by 6 mm. In
response to the retraction of the incisor, the upper lip re-
tracted 6 mm, and the lower lip retracted 4 mm. Subse-
quently, the proportion of the upper lip retraction
relative to maxillary incisor retraction was determined
to be a 0.75 ratio, whereas that for the lower lip was a
0.66 ratio in relation to the retraction of the mandibular
incisors (Table III).
The total treatment time was 38 months. Root re-
sorptions were considered to be acceptable (Fig 10).
Fig 10. Posttreatment panoramic and cephalometric The superimposition of cephalometric tracings shows
radiograph. the growth quantity and pattern that were essential fac-
(labrale inferius), Prn (pronasale), and Pog’ (soft tissue tors to achieve the results. In addition, significant im-
pogonium) were measured pre- and posttreatment. provements of the mandibular incisor inclinations and

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254 Saga et al

Fig 11. Superimposition of cephalometric tracings: black, pretreatment; red, posttreatment.

maxillary intrusion are demonstrated (Fig 11). Treatment lip retraction are explicated by treatment type, whereas
results were deemed stable after 5 years of active ortho- protrusion of the lower lip is correlated with initial incli-
dontic treatment (Fig 12). nation of the mandibular incisor, maxillomandibular
sagittal relationship, lower lip thickness, and sex.
Conversely, a study by Kuhn et al11 verified that the
DISCUSSION amount of horizontal movement of the most anterior
Overall, the final results achieved in the present case point of the maxillary incisor, the extent of bite opening,
can be considered to be satisfactory, exceeding the au- and the initial lip thickness are the main causal elements
thor's expectations, mainly because of excellent patient for predicting soft tissue profile modification in ortho-
compliance, which allowed the biomechanical approach dontic treatment, particularly for upper and lower lip
to work in a satisfactory manner. Otherwise, the treat- angulation. A change of 0.59 mm for the upper lip can
ment of skeletal Class II malocclusion involves growth be estimated for every millimeter of horizontal change
modification by orthopedic appliances such as func- of the most anterior point of the maxillary central
tional or headgear appliances, orthodontic compensa- incisor. Therefore, it can be speculated that, if large
tion with or without teeth extraction in patients with soft tissue changes are required (more lip retraction
mild to moderate skeletal discrepancies, and orthog- and a greater increase in lip thickness), it is necessary
nathic surgery in adult patients with severe skeletal dis- to maximize the degree of incisor protrusion correction.
crepancies. The patient required a significant amount of retraction
Estimation of the soft tissue profile modifications re- of the lips to correct esthetic and functional problems.
sulting from orthodontic treatment of Class II, Division 1 The performed tooth extractions provided necessary
malocclusion from initial patient morphology, types of spaces for lip repositioning. The incisor or lip retraction
treatment, sex, and age is complex and involves several ratios were 0.75 and 0.66 to upper and lower lips,
variables to describe their variations,9 with the literature respectively (Table III). As noted, the proportions differ
showing distinctive results. For example, Kasai10 found from those observed in other studies.9,11 Although
that changes of the lower lip can be predicted and mirror there may be a significant correlation between dental
the alterations of the hard tissue; nevertheless, changes movements and soft tissue changes in large samples,
in the upper lip demonstrate a weaker correlation with predictions for individual cases still are not completely
the hard tissue modification. In a corresponding view- reliable.
point, Maetevorakul and Viteporn9 found that upper Patients with initially thicker lips are likely to experi-
lip modification in the horizontal direction is less pre- ence less lip retraction than those with thinner
dictable than that of the lower lip. Variations in upper ones.9,11,12 Moreover, in female adolescents, the upper

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Saga et al 255

Fig 12. Photographs taken at 5 years posttreatment.

lip thickness average is 12 mm and average thickness for eversion (Table III). In addition, lip incompetence is
the lower lip is 11 mm, as measured at the vermilion multifactorial, and causal factors include short lips, lip
border to the inner lining of the lip.13 The thickness of prominence, protruded and proclined maxillary and
the patient's upper lip in the pretreatment phase was mandibular incisors, shorter cranial base, and bimaxil-
14 mm, which could be considered a thick lip. In the lary protusion.11 Then, retraction of the incisors would
posttreatment phase, the thickness of the upper lip assist in improving passive labial contact.
increased to 15 mm, which is in agreement with other The reference values of horizontal changes of the up-
studies.14,15 Although thick lips may respond less to per lip owing to maxillary central incisor movement
the retractions of the maxillary incisors, in this case, differ somewhat according to the based sample, for
there was a favorable result, with a maxillary incisor or example, white,11 black,16 or Japanese women.17 There-
upper lip retraction ratio above that reported in fore, ethnicity plays a considerable influence on soft tis-
another study.11 The lower lip also presented a thickness sue response determined by the orthodontic treatment.
above the mean (13 mm). However, there was a reduc- In Brazil, the population is quite mixed, containing
tion of 2 mm in the thickness of this lip. This reduction diverse ethnic patterns such as those from Europeans,
may be associated with the correction of the labial Africans, Asians, and natives, which makes the

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256 Saga et al

predictability of the soft tissue response even more chal- repositioning surgery (LeFort I osteotomy) was necessary.
lenging. The parents of the presented patient reported When guided bone regeneration was combined with
that they had African, European, and native ancestry. periodontal crown enlargement, the benefits shown on
Studies have shown that patients with a smaller ANB smiling were even better (60%).4 Nevertheless, she defi-
angle demonstrated less lip protrusion after treat- nitely had dentoalveolar extrusion of the maxillary ante-
ment.9,18 This phenomenon is probably explained by rior teeth (U1-stomium: 12 mm) (Table I), which
the fact that patients with lesser ANB angles often indicated incisor intrusion. In fact, as advocated by
require less dental compensation of the skeletal some authors, in some situations, tooth intrusion when
discrepancy and, therefore, present with lower associated with a decrease of overjet and overbite may
inclination of the mandibular incisors and in turn, a correct GS.22
less-protruding lower lip. In the reported patient, the The short upper lip and hyperactivity of the muscles
skeletal discrepancy was not totally corrected (posttreat- responsible for the movement of the upper lip are factors
ment ANB: 6
and Wits: 5 mm) (Table II). Even in this sit- to be approached in GS treatment.23-25 The patient's
uation, good positioning of the lips was achieved in upper lip length was 17 mm, which could be
relation to the S line. This probably occurred because considered a short lip. After orthodontic treatment,
of the favorable response of the lips to the retraction upper lip length increased by 4 mm (Table I). This could
of the incisors. be considered not only a natural growth effect but also a
Concerning the gingival esthetics, an exposure at consequence of Class II and maxillary incisor correction.
smiling amount of no greater than 3.0 mm is visually The extent of maxillary incisor exposure ranges from 2 to
desirable. Values higher than 3.0 mm are considered un- 4.5 mm in women and from 1 to 3 mm in men during the
esthetic, whereas a slight gingival display at smiling is resting posture of the lips. This feature is directly related
considered a youthfulness characteristic.19 The patient to the youthful aspects of the smile, and it normally de-
had 4.5 mm of gingival display, and this was one of creases throughout life owing to elongation of the upper
her chief complaints. The achieved reduction of lip by the aging of the tissues.24,26 The hyperactivity of
4.5 mm let the gingival exposure fall within normal labial musculature was not observed at the end of
values and the smile to become more esthetic and attrac- treatment.
tive (Table I). The effective use of mini-implants as a temporary
To appropriately treat the GS, it is necessary for clini- skeletal anchorage method to reduce overbite in
cians to diagnose its causes. To this end, treatment plan- nongrowing patients has been reported without side ef-
ning must consider the primary etiology, independently fects.27-29 However, case reports describing
or in combination of factors, which could include altered simultaneous intrusion and retraction of the maxillary
passive eruption, dentoalveolar extrusion, or vertical incisors to correct GS and overjet in growing patients
maxillary excess.20 following extractions are uncommon. In the presented
During teeth eruption, usually, the gingival tissue fol- case, besides the correction of the GS, intrusion of the
lows teeth movement. As they reach the occlusal plane, maxillary anterior teeth was expected to correct the
the marginal gingiva drifts apically and ends up being deep overbite, reduce the large interlabial gap, and
positioned adjacent to the cementoenamel junction. allow for the maxillary incisor retraction to improve
This entire movement course is called passive eruption. the Class II convex profile.
However, when gingiva does not drift to the estimated The primary issue in the current patient was the
location, it is labeled as altered passive eruption. Typi- excessive eruption of the maxillary incisors (U1-
cally, these teeth present with short clinical crowns. It stomion: 12 mm) (Table I). Therefore, intrusion of the
should be distinguished from accentuated wear extruded maxillary incisors would correct the GS by alve-
situations of the incisal edges. In altered passive eruption olar bone and gingival tissue remodeling. Moreover,
cases, the gingival sulcus depth is enlarged at probing skeletal anchorage would restrict vertical growth of the
and, in this condition, the appropriate treatment for GS alveolar bone.
is clinical crown augmentation via periodontal surgical In the presented case report, the maxillary incisors
procedures.20,21 Because the current patient did not were intruded by 1.7 mm, and the GS improved without
have short clinical crowns or enlarged gingival sulcus considerable side effects. The patient initially presented
depth, these factors were eliminated from etiologic with retroclined and retruded maxillary incisors (1.NA:
factors; therefore, no gingivectomy or gingivoplasty 5.5
and 1-NA: 0.5 mm). The presence of proclined
was indicated. In addition, she did not display excessive maxillary incisors tends to decrease the incisor display
vertical development or a hyperdivergent face and was at rest and in smiling. In contrast, uprighted or retro-
not classified as long-faced, so no maxillary apical clined maxillary incisors that could be a compensatory

February 2020  Vol 157  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Saga et al 257

feature of Class II malocclusion or occur after orthodon- 4. Ferreira CE, Brand~ao RC, Martinelli CB, Pignaton TB. Improving
tic anterior retraction without torque control tend to in- gingival smile by means of guided bone regeneration principles.
Dent Press J Orthod 2016;21:116-25.
crease the incisor exposition and worsen the GS by
5. Hunt O, Johnston C, Hepper P, Burden D, Stevenson M. The influ-
extrusion of the maxillary incisors (Table II).30 ence of maxillary gingival exposure on dental attractiveness rat-
With the placement of the mini-implants between ings. Eur J Orthod 2002;24:199-204.
the central and lateral roots, the resultant axis of the or- 6. Suzuki L, Machado AW, Bittencourt MA. An evaluation of the in-
thodontic force vectors was expected to be positioned fluence of gingival display level in the smile esthetics. Dent Press J
Orthod 2011;16:37.e31-10.
forward from the incisor's axis of resistance, which singly
7. Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral
would intrude and procline the maxillary incisors.31,32 maturation method: some need for clarification. Am J Orthod Den-
The position of the mini-implants did not interfere tofacial Orthop 2003;123:19A-20A.
with tooth movement, and the skeletal anchorage sys- 8. Rathod AB, Araujo E, Vaden JL, Behrents RG, Oliver DR. Extraction
tem assisted in the simultaneous 3-dimensional man- vs no treatment: long-term facial profile changes. Am J Orthod
Dentofacial Orthop 2015;147:596-603.
agement of the maxillary incisor retraction and
9. Maetevorakul S, Viteporn S. Factors influencing soft tissue profile
intrusion by controlling undesirable side effects and changes following orthodontic treatment in patients with Class II
improving the predictability of treatment results. Division 1 malocclusion. Prog Orthod 2016;17:13.
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11. Kuhn M, Markic G, Doulis I, G€ollner P, Patcas R, H€anggi MP. Effect
ment were compared, the faces of both groups were
of different incisor movements on the soft tissue profile measured
similar, although slightly flat.18 Soft tissue changes in in reference to a rough-surfaced palatal implant. Am J Orthod
the extraction-treated sample generally occurred in a Dentofacial Orthop 2016;149:349-57.
forward direction, whereas those in the untreated sample 12. Oliver BM. The influence of lip thickness and strain on upper lip
were in a downward and forward direction.8 Therefore, response to incisor retraction. Am J Orthod 1982;82:141-9.
13. Bergman RT, Waschak J, Borzabadi-Farahani A, Murphy NC. Lon-
extraction treatment does not necessarily unfavorably
gitudinal study of cephalometric soft tissue profile traits between
affect the profile in long-term follow-up. Hence, long- the ages of 6 and 18 years. Angle Orthod 2014;84:48-55.
term facial changes are a maturational question. 14. Talass MF, Talass L, Baker RC. Soft-tissue profile changes resulting
from retraction of maxillary incisors. Am J Orthod Dentofacial Or-
CONCLUSIONS thop 1987;91:385-94.
15. Kokodynski RA, Marshall SD, Ayer W, Weintraub NH, Hoffman DL.
A Class II, Division 1 malocclusion with severe GS was Profile changes associated with maxillary incisor retraction in the
successfully managed by the combined use of headgear postadolescent orthodontic patient. Int J Adult Orthod Orthognath
to control maxillary anteroposterior growth, anterior Surg 1997;12:129-34.
16. Brock RA 2nd, Taylor RW, Buschang PH, Behrents RG. Ethnic dif-
mini-implants to anchor maxillary incisor intrusion
ferences in upper lip response to incisor retraction. Am J Orthod
and restrict alveolar bone vertical growth, and extraction Dentofacial Orthop 2005;127:683-91: quiz 755.
of premolars to provide spaces for incisor retraction. An 17. Hayashida H, Ioi H, Nakata S, Takahashi I, Counts AL. Effects
attractive smile, passive lip seal, and an esthetic and of retraction of anterior teeth and initial soft tissue variables
balanced facial profile were achieved. Treatment results on lip changes in Japanese adults. Eur J Orthod 2011;33:
419-26.
were stable at 5 years after the procedures.
18. Zierhut EC, Joondeph DR, Artun J, Little RM. Long-term profile
changes associated with successfully treated extraction and non-
SUPPLEMENTARY DATA extraction Class II Division 1 malocclusions. Angle Orthod 2000;
70:208-19.
Supplementary data associated with this article can
19. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of
be found, in the online version, at https://doi.org/10. dentists and lay people to altered dental esthetics. J Esthet Dent
1016/j.ajodo.2018.09.021. 1999;11:311-24.
20. Rosenberg E, Torosian J. Periodontal problem solving. Interrela-
tionship of periodontal therapy and esthetic dentistry. Dent Clin
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