IJOI 35 iAOI CASE REPORT

Bimaxillary Protrusion and Gummy Smile Corrected

with Extractions, Bone Screws
and Crown Lengthening

Abstract
This case report describes the interdisciplinary treatment of a 25-year-old woman presenting with chief complaints of bimaxillary
protrusion and excessive gingival display (“gummy smile”). She was dissatisfled with her previous non-extraction orthodontic
treatment, rendered at age 10. The Discrepancy index (DI) for this severe malocclusion was 21. Orthodontic treatment involved
extraction of four premolars to correct protrusion, and skeletal anchorage via four minisscrews (2 anterior and 2 posterior) to intrude
the entire maxillary arch. Space closure utilizing maxillary extra-alveolar (E-A) bone screws reduced lip protrusion and the anterior
miniscrews were used to intrude the maxillary incisors. Following orthodontics, surgical crown lengthening was performed in the
maxillary anterior segment. 32 months of interdisciplinary treatment resulted in a near ideal result as evidenced by a Cast-Radiograph
Score (CRE) of 15 and Pink & White (dental esthetic) score of 3. (Int I Ortho Implantol 2014;35:40-60)

Key words:
Class I malocclusion, bimaxillary protrusion, surgical crown lengthening, self-ligating appliance, gummy smile

History and Etiology Diagnosis

SNA 78o, SNB 75o,

ANB 3o
SN-MP 41o,
FMA 32o
Fig. 1

Figs. 2
and 3
5 mm

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

Director, Morita dental clinic,

Board eligible, International Association for Orthodontists & Implantologists (Left)

Board eligible, International Association for Orthodontists & Implantologists (middle)

Founder, Beethoven Orthodontic Center

Publisher, International Journal of Orthodontics& Implantology (middle)

Consultant, International Journal of Orthodontics & Implantology (right)

Fig. 1: Pre-treatment facial photographs Fig. 4: Post-treatment facial photographs

Fig. 2: Pre-treatment intraoral photographs Fig. 5: Post-treatment intraoral photographs

Fig. 3: Pre-treatment study models (casts) Fig. 6: Post-treatment study models (casts)

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IJOI 35 iAOI CASE REPORT

Fig. 7: Fig. 8:
Pre-treatment lateral cephlometric and panoramic Post-treatment lateral cephlometric and panoramic
radiographs reveal root canal treatment in tooth #13. radiographs document the orthodontic result.
Bimaxillary protrusion and lip strain on closure is noted in
the cephalometric view.

Fig. 9: Cephalometric tracings were superimposed on the anterior cranial base, maxilla and mandible.

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

CEPHALOMETRIC Decrease the vertical dimension of the

SKELETAL ANALYSIS occlusion (VDO)
PRE-Tx POST-Tx DIFF. Maintain
SNA°
SNB°
ANB° Retract incisors
SN-MP° Intrude the entire maxillary dentition,
FMA° particularly the incisors
DENTAL ANALYSIS Modest increase
U1 TO NA mm to articulate with the lower arch
U1 TO SN°
L1 TO NB mm
L1 TO MP°
Retract the mandibular incisors
FACIAL ANALYSIS
Maintain
E-LINE UL
Modest increase
E-LINE LL
as buccal segments are uprighted

Treatment Plan
teeth #5, 13,
ABO 21 and 28
DI Ormco, Glendora, CA

OBS Newton’s A, Ltd., Hsinchu, Taiwan

Specific Objectives of Treatment IZC

all three planes

Retract
Intrude
Maintain

all three planes

Maintain

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IJOI 35 iAOI CASE REPORT

Appliances and Treatment Progress

Fig. 10

Fig. 11

0M
Fig. 10:
Ormco 1/4” 3.5oz “Fox”
The maxillary right first(#5) and left second(#13) premolars
were extracted and high torque brackets were bonded on
the incisors.

Fig. 12

Figs. 13-15
TAD 1M
Fig. 11:
The lower arch was bonded one month after the upper arch.
Standard torque brackets were used on all teeth. Note that
both first premolars were extracted.
3.5 oz

Fig. 16

.019x.025” SS
Fig.
14 16M

Fig. 12:
Inter-radicular OBSs were inserted between the central and
lateral incisors, and E-A OBSs were inserted in the zygomatic
crests. Incisor intrusion was accomplished with elastomer
chains.

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

a
16M

b
23M

c
27M

Fig. 13:
Diagrams and corresponding photographs illustrate the mechanics employed at progressive stages of treatment:
a. At 16 months the occlusal plane was gradually steepening.
b. At 23 months anterior bite turbos were bonded on the palatal surfaces of the maxillary central incisors.
c. In the 27th month, retraction force from the IZC miniscrews closes upper space but also provide lingual crown torque to the
upper incisors.

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IJOI 35 iAOI CASE REPORT

16M
16M

23M
Fig. 14: 23M
As extraction space closed, the right buccal segment tend
toward crossbite, so the archwire was expanded.

1/4” 3.5 oz

Figs. 17-19
Fig. 16:
The distance of 3 mm between the screws and main arch
wire from 16th to 23rd month have been reduced.

Fig. 15:
The force systems provided by the four OBSs and their overall effect on the maxillary arch are complex. The yellow arrow on
the left indicates the intrusive force applied to the incisors. The large red arrow is the retraction force anchored by the IZC OBS.
The small red arrow is the intrusive component on the posterior maxillary segment. The large blue arrow is the net resultant
force on the maxilla, and the blue circular arrow represents the moment of the retraction force around the center of resistance
of the maxilla (red dot with a cross).

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

Retention

Fig. 20

Fig. 17 Fig. 18

Surgical crown lengthening process #

CEJ
to alveolar crest

#
Figs. 17b,c and Fig 18a
19
CEJ

Fig. 17d Fig 18c

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IJOI 35 iAOI CASE REPORT

a b c

d e f

Fig. 17:
The surgical crown lengthening procedure for short clinical crowns (a) begins with bone sounding (b) relative to the attached
gingiva (c). The width of the attached gingiva is mapped with a dotted line (d). The gingivectomy is performed with a No. 15
blade (e) and the increased crown exposure (f) is assessed relative to the width of the remaining attached gingiva.

Final Evaluation of Treatment

#
CRE

Fig. 9

Fig. 4

gingival aspects
Discussion

gummy smile,
dental aspects

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

Fig. 19:
c The dentogingival complex can be measured by bone
sounding with a periodontal probe. The dimensions of the
normal dento-gingival complex are approximately
3.0 mm buccally and lingually, with a mean of 4.5 to 5.0 mm
interproximally.

Fig. 18:
Yellow lines represent the CEJs and black lines are the
alveolar bone level before osteoplasty (a). The white arrow
(a) shows that the biologic width of #10 was only ~1 mm (b).
After osteoplasty (b) the biologic width was corrected to
2.5 mm, and the gingiva was sutured with #4 Gore-Tex®
(Gore Medical Products, Flagstaff, AZ).

Extra-oral causes:

Fig. 21 Fig. 20:

Photos taken at 14th months of treatment show the maxillary
molars are tilted mesially because of inaccurate brackets
positioning.

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IJOI 35 iAOI CASE REPORT

VME

Fig. 21:
Ideal lip length in young adult females is from 20 to 22 mm,
whereas it is from 22 to 24 mm in young adult males.

HUL

2000

ADE

Fig. 22a Allergan Inc. Irvine, CA

passive eruption

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

a
Intra-oral causes:

e.g. phenytoin, cyclosporine, calcium

channel blockers etc

1968 c PNS
ANS Palatal
plane
Posterior
maxillary
Anterior
height
1976 maxillary
height

MGJ

Fig. 22: Occlusal plane canting in the sagittal plane:

Fig. 22
a. In anterior dentoalveolar extrusion (ADE), only the
anterior portion of the occlusal plane is canted
inferiorly.
soft tissue
b. Vertical maxillary excess (VME) involves inferior
positioning of both the anterior and posterior segments
with a flat but often steep occlusal plane.
c. Anterior and posterior maxillary height are measured
cephalometrically as shown.

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IJOI 35 iAOI CASE REPORT

Figs. 23 and
24

Decision tree :
Fig. 22a
Fig. 3
Fig. 22b

~11 mm

Fig. 24

Figs. 23 and 24
Fig. 24

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

Type I, A Type I, B Type II, A Type II, B

Gingivectomy O O X X

Osteoplasty X O X O

APF X X O O

Fig. 23:
Classification of altered passive eruption is important for determining the most appropriate surgical procedure(s) to correct it.

Fig. 24:
The decision tree is a flow chart for assessing excessive gingival display to determine the most appropriate clinical
management for a specific problem. The five determinants for decision making are: extent of the excessive gingival display,
clinical crown length, incisal wear, incisor exposure at rest, and the crown-root ratio.

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IJOI 35 iAOI CASE REPORT

a b c

Fig. 25: Smile type is classified as follows:

a. Commissure smile is a Cupid’s Bow configuration that is seen in ~67% of the population. The corners of the mouth are
elevated and projected anteriorly by the levator muscles of the upper lip. The teeth are exposed in a smile arc with a base
at the incisal edge of the maxillary central incisor.
b. Cuspid smile is seen in ~31% of the population. The shape of the lips is commonly visualized as a diamond. The levator
labii superior muscles contract first, exposing the maxillary cuspids, then the corners of the mouth contract projecting the
lips upward and outward.
c. Complex smile is seen in ~2 % of the population. The shape of the lips are typically illustrated as two approximating
chevrons. The levators of the upper lip and corners of the mouth contract simultaneously with the depressors of the lower
lip, to expose all the upper and lower teeth.

a b c

Fig. 26: Smile line is classified as follows:

a. Low smile line, exposing less than 75% of the maxillary incisors and no gingiva, is seen in 20.48% of the population.
b. Average smile line, exposing 75-100% of the maxillary anterior teeth along with interproximal gingiva, is seen in 68.94% of
the population.
c. High smile line, exposing 100% of the anterior segment along with a contiguous band of gingiva., is seen in 10.57% of the
population.

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

Fig. 27:
Pre- and post-treatment images of the current patient’s smile. The gummy smile has been improved remarkably by
orthodontics and surgical crown lengthening.

Fig. 26

Fig. 27

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IJOI 35 iAOI CASE REPORT

7. Wu H, Lin J, Zhou L, Bai D. Classification and craniofacial

features of gummy smile in adolescents. J Craniofac Surg
2010;21:1474-1479.
8. Fushima K, Kitamura Y, Mita H, Sato S, Suzuki Y, Kim YH.
Significance of the cant of the posterior occlusal plane in class
Conclusion II division 1 malocclusions. Eur J Orthod 1996;18:27-40.
9. Janson GR, Metaxas A, Woodside DG. Variation in maxillary
and mandibular molar and incisor vertical dimension in
12-year-old subjects with excess, normal, and short lower
anterior face height. Am J Orthod Dentofacial Orthop
1994;106:409-18.
10. Garber DA, Salama MA. The aesthetic smile: diagnosis and
treatment. Periodontol 2000 1996;11:18-28.
11. Simon Z, Rosenblatt A, Dorfman W. Eliminating a gummy
smile with surgical lip repositioning. Journal of Cosmetic
Dentistry 2007;23:100-108.
12. Po l o M . B o tu l i nu m t ox i n ty p e A (B o t ox ® ) f o r th e
neuromuscular correction of excessive gingival display on
smiling (gummy smile). Am J Orthod Dentofacial Orthop
2008; 133:195-203.6
Acknowledgement 13. Newman MG, Takei HH, Carranza FA. Carranza’s Clinical
Periodontology. 9th ed. Saunders 2002, p. 31.
14. Cohen E. Atlas of cosmetic and reconstructive periodontal
surgery. 3rd ed. Decker BC 2007, p. 259.
15. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New
approach to the gummy smile. Plast Reconstr Surg 1999; 104:
discussion 51-2, 1143-1150.
16. Philips E. The classification of smile patterns. J Can Dent Assoc
References 1999; 65:252-254.
1. Lang NP, Löe H. The relationship between the width 17. Tjan A, Miller G. Tjan AHL, Miller GD. Some esthetic factors
of keratinized gingiva and gingival health. Journal of in a smile. J Prosthet Dent 1984; 51: 24-28.
Periodontology 1972;43:623-627. 18. Peck S. Peck L, Kataja M. Some vertical lineaments of lip
2. Yeh HY, Chang CH. Robert WE. Implant-orthodontic position. Am J Orthod Dentofac Orthop 1992;101:516-524.
combined treatment for gummy smile with multiple missing 19. Kaya B, Vyar R. Influence on smile attractiveness of the smile
teeth. Int J Ortho Implantol 2013;32:16-32. arc in conjunction with gingival display. Am J Orthod Dentofac
3. Kois J. Altering gingival levels. The restorative connection. Orthop 2013;144(4):541-547.
1.Biologic variables. J Esthet Dent 1994; 6:3-9. 20. Vig RG, Brundo GC. The kinetics of anterior tooth display. J
4. Hulsey CM. An esthetic evaluation of lip-teeth relationships Prosthet Dent 1978;39:502-504.
present in the smile. Am J Orthod Dentofac Orthop 1970; 21. Darwin C. The expression of the emotions in man and animal.
57:132-144. London, John Murray, 1872, Chapter 14, p. 347-366.
5. Chen CK. Diagnosis and therapy of gummy smile. Beethoven
Podcast Encyclopedia in Implant Forum No.38. Hsinchu:
Newton’s A Ltd; 2013.6.28.
6. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod
1992; 62: discussion 1-2, 91-100.

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

LINGUAL POSTERIOR X-BITE

Discrepancy Index Worksheet 1 pt. per tooth Total = 0

0

CASE # 1 (Rev. 9/22/08)

BUCCAL POSTERIOR X-BITE
TOTAL D.I. SCORE 21
25
2 pts. per tooth Total = 02
OVERJET
CEPHALOMETRICS (See Instructions)
0 mm. (edge-to-edge) = 1 pt.
1 – 3 mm. = 0 pts. ANB 6° or -2° = 4 pts.
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 3 pts.
Each degree < -2° x 1 pt. =
7.1 – 9 mm. = 4 pts.
> 9 mm. = 5 pts.
Each degree > 6° x 1 pt. =
Negative OJ (x-bite) 1 pt. per mm. per tooth =
SN-MP
38° = 2 pts.
Total = 2
5
Each degree > 38° x 2 pts. =
OVERBITE
26° = 1 pt.
0 – 3 mm. = 0 pts.
3.1 – 5 mm. = 2 pts. Each degree < 26° 4 x 1 pt. = 4
5.1 – 7 mm. = 3 pts.
Impinging (100%) = 5 pts. 1 to MP 99° = 1 pt.
Each degree > 99° 2 x 1 pt. = 2
Total = 2
5

Total = 28
ANTERIOR OPEN BITE
0 mm. (edge-to-edge), 1 pt. per tooth OTHER (See Instructions)

then 1 pt. per additional full mm. per tooth Supernumerary teeth x 1 pt. =
Ankylosis of perm. teeth x 2 pts. =
Total = 00 Anomalous morphology x 2 pts. =
Impaction (except 3rd molars) x 2 pts. =
Midline discrepancy ( 3mm) @ 2 pts. =
LATERAL OPEN BITE Missing teeth (except 3rd molars) x 1 pts. =
Missing teeth, congenital x 2 pts. =
2 pts. per mm. per tooth Spacing (4 or more, per arch) x 2 pts. = 2
Spacing (Mx cent. diastema 2mm) @ 2 pts. = 2
Total = 0
0 Tooth transposition x 2 pts. =
Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
CROWDING (only one arch) Addl. treatment complexities 3 x 2 pts. = 6
1 – 3 mm. = 1 pt. Identify: Severe gummy smile and bimaxillary protrusion
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 4 pts. Total = 46
> 7 mm. = 7 pts.
IMPLANT SITE
Total = 1
7
OCCLUSION
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side 2 pts.
Full Class II or III = 4 pts. per side pts.
Beyond Class II or III = 1 pt. per mm. pts.
additional

Total = 2
0

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IJOI 35 iAOI CASE REPORT

Occlusal Contacts

Cast-Radiograph Evaluation 5
Interim-Treatment Progress

Total Score:
15
Alignment/Rotations

4 1 1 1 1
1 1

1 1

Marginal Ridges

1 Occlusal Relationships
11

Interproximal Contacts
Buccolingual Inclination
1
1 1

Overjet Root Angulation

0 3
1 1

1
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.

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 Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening IJOI 35

IBOI Pink & White Esthetic Score (Before Surgical Crown Lengthening)
Total Score: = 7
1. Pink Esthetic Score
Total = 4
1. Mesial Papilla 0 1 2

6 2. Distal Papilla 0 1 2
5
4 3. Curvature of Gingival Margin 0 1 2
2 3 1
4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

1. M & D Papillae 0 1 2

2. Keratinized Gingiva 0 1 2

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score ( for Micro-esthetics ) Total = 3

1. Midline 0 1 2

2. Incisor Curve 0 1 2
1
3. Axial Inclination (5°, 8°, 10°) 0 1 2

3
4. Contact Area (50%, 40%, 30%) 0 1 2
4 5 6
5. Tooth Proportion (1:0.8) 0 1 2
2
6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

5 4. Contact Area (50%, 40%, 30%) 0 1 2

5. Tooth Proportion (1:0.8) 0 1 2

6. Tooth to Tooth Proportion 0 1 2

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IJOI 35 iAOI CASE REPORT

IBOI Pink & White Esthetic Score (After Surgical Crown Lengthening)
Total Score: = 3
1. Pink Esthetic Score
Total = 2
1. Mesial Papilla 0 1 2

6 2. Distal Papilla 0 1 2
5
4 3. Curvature of Gingival Margin 0 1 2
2 3 1
4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

1. M & D Papillae 0 1 2
4 2. Keratinized Gingiva 0 1 2
3

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score ( for Micro-esthetics ) Total = 1

1. Midline 0 1 2

2. Incisor Curve 0 1 2
1
3. Axial Inclination (5°, 8°, 10°) 0 1 2

3 4. Contact Area (50%, 40%, 30%) 0 1 2

4 5 6
5. Tooth Proportion (1:0.8) 0 1 2
2
6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

5 4. Contact Area (50%, 40%, 30%) 0 1 2

5. Tooth Proportion (1:0.8) 0 1 2

6. Tooth to Tooth Proportion 0 1 2

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