Management of Gummy smile

Management of
Gummy Smile
Arun Bosco Jerald
2018 batch
Seminar on:

Contents
• Introduction
• Etiology
• Clinical evaluation
• Smile evaluation
• Components of a balanced smile
• Periodontal evaluation
• Smile Analysis
• Treatment Modalities
• Orthopaedic
• Restorative And Periodontal
• Orthodontic
• Surgical Correction
• Conclusion
• References

Introduction
• The smile is a complex facial expression that is associated with beauty.
• It has an important role in the determination of the first impression of
a person.
• Facial expressions and the smile are key components for non verbal
communication
• Smile is more than a form of communication; it is kind of socialization
and attraction.

• Webster’s dictionary
Smile is a pleased or amused expression of the face, formed by
curling of the mouth upward.
• The evaluation of smile has become an important part of our clinical
assessment with a greater emphasis on dynamic evaluation.
• Among the frontal features; competence of lips, increased incisal show
and gummy smile have become the major concern of the pateints.

• Gingiva, lips, and teeth are the 3 major structures that affect smile.
• The alignment, position, and size of maxillary incisors, as well as the
gingival line, affect whether a smile is esthetic.
• Excessive gingival display (EGD) when smiling is commonly termed as
Gummy Smile.
• Also known as: High lip line
Full denture smile

Etiology
• Gingival display is a descriptive term rather than a diagnosis which
would mandate the initiation of specific therapy.
• While numerous factors can cause excess gingival display, it is common
for the condition to occur as a result of interplay of several etiologies.

Skeletal factors
Vertical maxillary excess
Rotations of maxilla
Dental factors
Short clinical crown
Anterior dentoalveolar extrusion
Loss of torque on the anteriors
Increased overjet and
Increased overbite
Soft tissue
Short upper lip/hyperfunctional
Musculature
Short philtrum
More superiorly positioned upper
lip
Periodontal factors
Gingival problems related to
delayed passive eruption
Gingival hyperplasia
GUMMY
SMILE

Clinical Evaluation
❖Facial symmetry and proportions in both frontal and lateral views
Facial Balance:
• Its an assessment of vertical jaw relationship
• Three ratios

First ratio: “Vertical thirds”
• Upper third: Trichion to Glabella
• Middle third: Glabella to Subnasale
• Lower third: Subnasale to Soft tissue Menton
• Ratio should be 1:1:1

Second ratio:
• Subnasale to U/L Stomion : U/L Stomion to Soft tissue Menton
• The ratio should be 1:2
Third ratio:
• Subnasale to Vermillion cutaneous border of L/L : Vermillion
cutaneous border of L/L to Soft tissue Menton
• The ratio should be 1:1

❖Evaluation of lip posture and incisor prominence
• Excessive separation of the lips at rest is called lip incompetence.
• The general guideline that holds for all racial groups is that lip
separation at rest should be not more than 3-4 mm
• Increased interlabial gap is seen in:
• Anatomic short upper lip
• Vertical maxillary excess
• Mandibular protrusion with open bite

• Decreased interlabial gap is seen in:
• Vertical maxillary deficiency
• Anatomically long upper lip
• Mandibular retrusion with deep bite

❖Lip prominence
• Is evaluated by observing the distance that each lip projects forward
from soft tissue points A and B.
• Lip prominence of more than 2 to 3 mm in the presence of lip
incompetence indicates dentoalveolar protrusion.

• Lip prominence in the context of the relationship
of the lips to the nose and chin can be assessed by
drawing the E-line (esthetic line) from the nose to
the chin and to look at how the lips relate to this
line.
• The guideline is that they should be on or slightly
in front of the E-line. (Proffit)
• Lower lip should be 0-2mm away (Reyneke)

Smile evaluation
Basic Classification of the Smile
• Posed or Social Smile
• Voluntary
• Static
• Not elicited by emotion
• Fairly Reproducible
• Un-Posed or Emotional Smile
• Involuntary & Spontaneous
• Dynamic
• Elicited by joy or mirth
• Hardly Reproducible
• Characterized by more lip elevation than posed smile

Three styles of smile - Rubin L.R (Plast. Reconstr. Surg, 1974)
• The cuspid /commissure smile,
• The complex / full-denture smile, and
• The Mona Lisa smile
• The cuspid or commissure smile
• Characterized by the action of all the elevators of the upper lip,
raising it like a window shade to expose the teeth and gingival
scaffold.

• The complex or full-denture smile
• Characterized by the action of the elevators of the upper lip and the
depressors of the lower lip acting simultaneously, raising the upper
lip like a window shade and lowering the lower lip like a window.
• The Mona Lisa smile
• Characterized by the action of the zygomaticus major muscles,
drawing the outer commissures outward and upward, followed by a
gradual elevation of the upper lip.
• Patients with complex smiles tend to display more teeth and gingiva
than patients with Mona Lisa smiles.

Amount of incisor and gingival display:
Vig & Brundo, J Prosthet Dent, 1978
• A normal gingival display between the inferior border of the upper lip
and the gingival margin of the maxillary anterior teeth during a posed
smile is 1 -2 mm
• The maxillary anterior teeth should be completely displayed during a
full smile .

Tjan, Miller and The performed a semi quantitative study of smil-line
variations in 1984
• The study divided the smiles into three categories:
Low smile displaying less than 75% of the clinical crown height of the
maxillary anterior teeth
Average smile revealing 75-100% of the maxillary anterior crown height
High smile exposing a band of contiguous maxillary gingiva

• Among these three categories, there was a sex difference in smile-line
frequency;
• Low smile lines were predominantly a male characteristic and
• High smile lines were predominantly a female characteristic
• The prevalence of gummy smile is 10% among the population aged
between 20 and 30 years, and is more common among women than men

Allen E P (Dent Clin North Am1998)
• Stated that gum exposure of less than 2-3 mm can be considered
attractive, with overexposure (> 3 mm) generally considered
unattractive;
however, perception of excessive gingival display is also subject to
cultural and ethnic preferences.

Kokich et al., J Esth Dent,1999
• In a normal smile, the gingival display between the gingival margin of
the maxillary central incisors and the inferior border of the upper lip is
approximately 1-2 mm.
• Dentists and nonprofessionals believe that smile esthetics are
negatively affected when gingival display between the gingiva and the
lip exceeds 4 mm.

Morley ratio (Morley J, 1999)
• The vertical aspects of smile anatomy are the degree of maxillary
anterior tooth display, upper lip drape, and gingival display.
• In a youthful smile, 75-100% of the maxillary central incisors should
be positioned below an imaginary line drawn between the commissures

• According to Chang C et.al, (AJODO,2011), the ideal elevation of the
lip on smile for adolescents is slightly below the gingival margin with
2mm of tooth coverage,
The acceptable range of tooth display is from minimal tooth coverage
of 1 mm up to 4 mm coverage of the incisor crown.
Beyond that, the smile appearance is less attractive.

The Eight Components of a Balanced Smile
• ROY SABRI, JCO 2005

1. Lip Line
• The lip line is the amount of vertical tooth exposure in smiling - ie,
the height of the upper lip relative to the maxillary central incisors.
• As a general guideline, the lip line is optimal when the upper lip reaches
the gingival margin, displaying the total cervicoincisal length of the
maxillary central incisors, along with the interproximal gingivae.

• Female lip lines are an average 1.5mm higher than male lip lines,
1-2mm of gingival display at maximum smile could be considered
normal for females.
• Dental professionals have been conditioned to see a “gummy smile” as
undesirable, but some gingival display is certainly acceptable, and is
even considered a sign of youthful appearance.
(Peck S, Peck L and Kataja; AO- 1992)

• The starting point of a smile is the lip line at rest, with an average
maxillary incisor display of 1.91mm in men and nearly twice that
amount, 3.40mm, in women. (Vig and Brundo, J. Prost. Dent, 1978)
• With aging, there is a gradual decrease in exposure of the maxillary
incisors at rest and, to a much lesser degree, in smiling.
• This steady decline in maxillary tooth exposure at rest is accompanied
by an increase in mandibular incisor display.

• Peck S, Peck L and Kataja; AO- 1992
• To measure the upper lip smile line:
• A vertical axis graduated in millimeters is visualized along the
soft tissue facial midline. A perpendicular, tangent to the cervical
margin of the upper central incisor defines the horizontal axis.

• The amount of vertical exposure in smiling depends on the following
six factors.
• Upper Lip Length
• Lip Elevation
• Vertical Maxillary Height
• Crown Height
• Vertical Dental Height
• Incisor Inclination

i) Upper Lip Length
• The normal lip length at rest, as measured from Subnasale to the most
inferior portion of the upper lip at the midline is 20 ± 2 mm for females
and 22 ± 2 mm for males (Reyneke J P)
UPPER LIP LENGTHS FROM VARIOUS STUDIES (mm)
Study Male Female
Burstone C J (Am. J. Orthod. 1967) 23.8 ± 1.5 20.1 ± 1.9
Farkas et al. (Am. J. Orthod. 1984) 21.8 ± 2.2 19.6 ± 2.4
Powell and Humphreys (1984) 23.8 ± 1.5 20.1 ± 1
Wolford L M (Plast. Reconstr. Surg, 1988) 22 ± 2 20 ± 2
Peck S, Peck L. and Kataja (Am. J. Orthod. 1992) 23.4 ± 2.5 21.2 ± 2.4
Arnett G.W. and Bergman (Am. J. Orthod. 1993) 19-22

• What is significant, however, is the relationship of the upper lip to the
maxillary incisors and to the commissures of the mouth.
• Lip length should be roughly equal to the commissure height, which is
the vertical distance between the commissure and a horizontal line
from subnasale.

• It is not easy to alter commissure height, but lip lengthening is possible
with lip surgery, either as a single procedure or in combination with a
Le Fort I osteotomy.
• In adolescents, a short upper lip relative to commissure height could be
considered normal because of the lip lengthening that continues even
after vertical skeletal growth is complete.
• It is interesting to note that a short upper lip is not always associated
with a high lip line; on the contrary, the upper lip was found to be
longer in a gingival-display group than in a non-displaying sample.

Short upper lip
• When lip length is 18mm or less
• In addition there will be:
• Increased interlabial gap
• Increased incisor exposure
• Normal lower face height

ii) Lip Elevation
• In smiling, the upper lip is elevated by about 80% of its original length,
displaying 10mm of the maxillary incisors.
• Women have 3.5% more lip elevation than men.
(Rigsbee, Sperry and BeGole; Int. J. Adult Orthod. Orthog. Surg.,1988)
• Actually, there is considerable individual variability in upper lip
elevation from rest position to the full smile, ranging from 2-12mm,
with an average of 7-8mm.
(Sarver D.M. and Weissman S.M. Angle Orthod.,1991)

• If a gingival smile is caused by a hypermobile lip, it would be a mistake
to correct it with aggressive incisor intrusion or maxillary impaction
surgery, because that would result in little or no incisor display at rest
and thus make the patient look older.
• Excessive lip elevation should therefore be recognized as a limiting
factor
• Likewise, if a low lip line is due to a hypomobile lip, extensive incisor
extrusion would result in an overbite with excessive incisor display at
rest.

iii) Vertical Maxillary Height
• When upper lip length and mobility are normal, a gingival smile with
excessive incisor display at rest can be attributed to vertical maxillary
excess.
• This kind of “skeletal” gingival smile is generally associated with
excessive lower facial height.
• Conversely, a low lip line with no incisor display at rest is “skeletal”
when associated with inadequate lower facial height due to a vertically
deficient maxilla.

• The best reference for impacting or lengthening the maxilla is the
incisor display at rest, taking upper lip length and any incisor attrition
into account.
• The full smile does not make a good reference, partly because of the
individual variation in lip mobility.
• A short upper lip should not be treated by shortening the maxilla
unless the facial outline can accommodate such a change.
• It should also be noted that in maxillary impaction, the upper lip
shortens by as much as 50% of the surgical skeletal intrusion. (Sarver
D.M. and Weissman S.M. Angle Orthod.,1991)

iv) Crown Height
• The average vertical height of the maxillary central incisor is 10.6mm in
males and 9.8mm in females.
• A short crown can be due to attrition or excessive gingival encroachment.
• If there is little or no incisor display at rest, but the lip line is normal in
smiling, the crown height can be increased incisally with cosmetic
dentistry.
• A gingivectomy or a crown-lengthening procedure with crestal bone
removal is recommended when short clinical crowns are associated with a
gingival smile and a normal incisor display at rest.

v) Vertical Dental Height
• A deep bite should be corrected by maxillary incisor intrusion in a pt
with excessive incisor display at rest, but with posterior extrusion
and/or lower incisor intrusion in a pt with a normal lip line at rest.
• The opposite applies to an open bite, which should be corrected by
maxillary incisor extrusion if there is inadequate incisor display at rest,
but with posterior intrusion and/or lower incisor extrusion if the lip
line is normal at rest.

vi) Incisor Inclination
• Proclined maxillary incisors, whether in a Class II, division 1 mo or in
a Class III compensation, tend to reduce the incisor display at rest and
in smiling.
• Uprighted or retroclined maxillary incisors, as seen in Class II, division
2 mo or after orthodontic retraction without torque control, tend to
increase the incisor display.
• Maxillary incisor inclination can best be assessed on profile and oblique
smiling photographs, which should become standard orthodontic
records.

2. Smile Arc
• The smile arc is the relationship between a hypothetical curve drawn
along the edges of the maxillary anterior teeth and the inner contour
of the lower lip in the posed smile.
• The curvature of the incisal edges appears to be more pronounced for
women than for men, and tends to flatten with age.
• The curvature of the lower lip is usually more pronounced in younger
smiles.

• In an optimal smile arc - described as “consonant”- the curvature of the
maxillary incisal edges coincides with or parallels the border of the
lower lip in smiling.
• In a “nonconsonant” smile arc, the maxillary incisal edges are either flat
or reversed relative to the curvature of the lower lip.

3. Upper Lip Curvature
• The upper lip curvature is assessed from the central position to the
corner of the mouth in smiling.
• It is upward when the corner of the mouth is higher than the central
position, straight when the corner of the mouth and the central
position are at the same level, and downward when the corner of the
mouth is lower than the central position.

4. Lateral Negative Space
• The transverse dimension of the smile is also referred to as “transverse
dental projection”.
• Lateral negative space is the buccal corridor between the posterior
teeth and the corner of the mouth in smiling.
• Orthodontists refer to buccal corridors as “negative” spaces to be
eliminated by transverse maxillary expansion

5. Smile Symmetry
• Smile symmetry, the relative positioning of the corners of the mouth
in the vertical plane, can be assessed by the parallelism of the
commissural and pupillary lines.
• Although the commissures move up and laterally in smiling, studies
have shown a difference in the amount and direction of movement
between the right and left sides.
• A large differential elevation of the upper lip in an asymmetrical smile
may be due to a deficiency of muscular tonus on one side of the face.

• Myofunctional exercises have been recommended to help overcome this
deficiency and restore smile symmetry.
• An oblique commissural line in an asymmetrical smile can give the
illusion of a transverse cant of the maxilla or a skeletal asymmetry

6. Frontal Occlusal Plane
• The frontal occlusal plane is represented
by a line running from the tip of the right
canine to the tip of the left canine.
• A transverse cant can be caused by
differential eruption of the maxillary
anterior teeth or a skeletal asymmetry of
the mandible

• This relationship of the maxilla to the smile cannot be seen on
intraoral images or study casts, and smile photographs can also be
misleading.
• Therefore, clinical examination and digital video documentation are
essential in making a differential diagnosis between smile asymmetry, a
canted occlusal plane, and facial asymmetry.
• Having the patient bite on a tongue blade or a mouth mirror in the
premolar area during the clinical examination is a good way to
recognize an asymmetrical cant of the maxillary frontal occlusal plane

7. Dental Components
• The first six components of the smile considered the relationship
between the teeth and lips and the way the lips and soft tissue frame
the smile. A pleasant smile also depends on the quality and beauty of
the dental elements it contains and their harmonious integration.
• Dental components of the smile include
• the size, shape, color, alignment, and crown angulation (tip) of the
teeth;
• the midline and
• arch symmetry.

8. Gingival Components
• Gingival components of the smile are color, contour, texture, and
height of the gingivae.
• Inflammation, blunted papillae, open gingival embrasures, and uneven
gingival margins detract from the esthetic quality of the smile
• The gingival margins can be leveled by orthodontic intrusion or
extrusion or by periodontal surgery, depending on the lip line, the
crown heights, and the gingival levels of the adjacent teeth.
• Gingival enlargement

Periodontal evaluation
• Altered passive eruption
• Active eruption
• The occlusal movement of the tooth as it emerges from its crypt
in the gingiva. This phase ends when the tooth makes contact
with the opposing tooth in the oral cavity .
• Passive eruption
• A normal condition in which the gingival margins recede apically
to the level of the CEJ after the tooth has erupted completely.

• In cases in which the gingival margins fail to recede to the level of the
CEJ, the condition is named Altered Passive Eruption.
• Because the gingival tissues are positioned coronal to the CEJ, the teeth
appear short and square
• This condition may involve multiple teeth or an isolated tooth. The
incidence of altered passive eruption in the general population is about
12%.

• excessive amount of keratinized
gingiva with normal alveolar
crest–to–CEJ relationship
Type 1A
• excessive amount of keratinized
gingiva with osseous crest at the
CEJ
Type 1B
• normal amount of keratinized
gingiva with normal alveolar
crest–to–CEJ relationship
Type 2A
• normal amount of keratinized
gingiva with osseous crest at the
CEJ level
Type 2B

Smile Analysis
• Marc B Ackerman and James L Ackerman; JCO, 2002
• From the video, the frame that best represents the patient’s social smile
is selected, captured with a program called Screen Snapz, and saved as
a JPEG file.
• The smile image is then opened in a program called SmileMesh, which
measures 15 attributes of the smile.
• This methodology was first used manually by Hulsey J M (AJO 1970)
and later modified and computerized by Ackerman J.L., Ackerman M.B.;
Brensinger C.M and Landis J.R (Clin. Orth. Res., 1998)

• The diagnostic part of smile analysis begins with the creation of a
problem list.
• The first set of records analyzed is the extraoral photographs
• In addition to the standard frontal at rest, frontal smile and profile at
rest images, Sarver and Ackerman recommend 4 additional views:
• Profile smile
• Oblique smile
• Frontal smile closeup
• Oblique smile closeup

• Consideration should be given to the vertical and lateral attributes of
the smile as well as to the cant of the transverse occlusal plane.
• The smile image is a better indication of transverse dental asymmetry
than the frontal intraoral view or even an anteroposterior cephalogram
• Next, the cant of the maxillary occlusal plane relative to Frankfort
horizontal should be assessed visually on the lateral cephalogram and
measured on the tracing.

• Vertical and anteroposterior skeletal and dental relationships are noted.
• Panoramic and supplemental intraoral radiographs are also analyzed
• Finally, the plaster study casts are evaluated for static occlusal
relationships and tooth-size discrepancies.
• The smile component of the orthodontic problem list consists of
descriptive terms such as increased maxillary incisor display,
unfavorable Morley ratio, excess gingival show, flat or reverse smile
arc, asymmetric cant of the maxillary anterior transverse occlusal
plane, and obliterated buccal corridors, to name a few.

• The clinician should rank these smile attributes in order of their
importance in creating a balanced smile.
• The final problem list will help the orthodontist to assess the viability
of different treatment options and select the appropriate
mechanotherapy for optimal smile design.

Altered / delayed passive eruption
• The goal of the crown lengthening procedure is to expose virtually all
of the anatomic crown
• Distance from crest of gingiva to alveolar crest is 5mm -
SUFFICIENT CREVICE DEPTH
• 2mm of gingiva is removed
GINGIVECTOMY
• Distance from crest of gingiva to crest of bone is 3mm
(bone sounding)
• SHORT CLINICAL CROWNS WITH INSUFFICIENT GINGIVAL
CREVICE
APICALLY
REPOSITIONED
FLAP

Morphologically short upper lip
• Correction of short philtrum can be achieved with V-Y cheiloplasty
performed as an isolated procedure or along with Lefort I impaction or
Rhinoplasty.
• The V-Y procedure helps in increasing the length of the upper lip but
when combined with rhinoplasty, the amount of tissue available for lip
lengthening is drastically increased

• In V-Y cheiloplasty, an incision is made in the anterior maxilla in the
vestibule, with a vertical incision behind the philtrum.
• Mattress sutures are then used to close these incisions, resulting in a
vertical scar closure, and reorientation of the muscles to reduce the
mobility of the upper lip on smile

Hyperactive upper lip
• If the facial height, gingival levels, lip length, length of the central
incisors are all within the acceptable limits in a patient with EGD the
likely DD is hyperactive upper lip.
• In a patient with hyperactive upper lip ,the lip may translate 1.5 to 2
times more than the normal distance

Lip repositioning technique
• The procedure restricts the muscle pull of the elevator lip muscles by
shortening the vestibule, thus reducing the gingival display while
smiling

• Partial thickness incision at muco gingival junction.
• 2nd incision parallel to it at 10-12 mm on labial mucosa.
• Both the incisions are approximated at mesial line angles of maxillary
molars.
• Tissue excision should be double the amount of gingival display.

• Effective procedure to reduce gingival display by positioning the upper
lip in a coronal location
• Contraindicated in patients with insufficient attached gingiva

Injection of Botox
• Botulinum toxin is produced by the anaerobic bacterium Clostridium
botulinum.
• This toxin acts by cleaving the synaptosomal-associated protein
(SNAP-25) and inhibiting the release of acetylcholine, thus preventing
muscle contraction.
• Among the 7 different serotypes of botulinum toxin, Type A (BTX-A)
is the most potent and the most commonly used one clinically.

• Botox is a purified BTX-A isolated from the fermentation of C
botulinum. (Allergan, Irvine, Calif)
• It is a stable, sterile, vacuum-dried powder that is diluted with saline
solution without preservatives.
• Polo M (AJODO, 2005) introduced the use of BTX for patients with
hyperfunctional lip elevator muscles and reported a significant
reduction in gingival display with the use of electromyographic
guidance.

• Garcia’s report stated that the toxin can spread through an area of 15
to 30 mm (Garcia A, Fulton JE Jr., Dermatol Surg. 1996)
• Considering the diffusion and the immediacy of the toxin, it is crucial
for the clinician to understand the distribution and morphology of the
target muscles, so that highly selective deactivation of muscles can be
performed while a natural smile is maintained.

• BTX-A injections (2.5 units in both right and left overlapping points
LLSAN and LLS, and Zm muscles) are given for the neuromuscular
correction of excessive gingival display caused by hyperfunctional
upper lip elevator muscles .
• It is effective and statistically superior to baseline smiles , although the
effect is transitory.

• The mean gingival exposure reduction was 5.2 mm.
• Gingival display gradually increased from 2 weeks post-injection
through 24 weeks, but, at 24 weeks, average gingival display still had
not returned to baseline values. (Polo M, AJODO, 2005)

Plaque/drug-induced gingival enlargement
• It is most often related to dental plaque and inflammation but can be
associated with medication such as phenytoin, cyclosporine, and
calcium channel blockers.
• Of all cases of DIGO, about 50% are attributed to phenytoin, 30% to
cyclosporins and the remaining 10-20% to calcium channel blockers.

• Treatment:
Treatment of this condition should focus on
meticulous oral hygiene.
Substitution of the drug causing enlargement
Sometimes, periodontal surgery is needed to eliminate
the excessive amount of soft tissues.

Short clinical crown
Short
clinical
crown
Attrition
Partial
eruption
Gingival
enlargement
•10.6mm in males
•9.8mm in females.
Average vertical height of
maxillary incisor:
MANAGEMENT
CROWN LENGTHENING
RESTORATIVE PROCEDURES
COMBINATION

Loss of torque or palatally tipped maxillary
incisors Loss of torque
class II div 2 After orthodontic
retraction
Poor torque control
Increased incisal
display
MANAGEMENT :
If iatrogenic – incorporation of torque in the wire

Anterior dentoalveolar extrusion
• Overeruption of the maxillary incisors with their dentogingival
complex leads to a more coronal position of the gingival margins and
excessive gingival display.
• In cases with deep bite, there is usually discrepancy in the occlusal
plane between the anterior and posterior segments

MANAGEMENT
Orthodontic
intrusion of the
involved teeth
Surgical periodontal
correction with or
without adjunctive
restorative therapy,
An interdisciplinary
comprehensive
treatment plan.

Orthodontic intrusion
• Intrusion refers to the apical movement of the geometric center of the
root (Centroid) with respect to the occlusal plane or plane based on the
long axis of the tooth. (Burstone)
• Factors to determine whether the incisors to be intruded or not:
• Incisor visibility at rest
• Lip length
• Overbite

• Three types:
(A)Absolute intrusion
(B)Relative intrusion
achieved by preventing eruption of the incisors while growth
provides vertical space into which the posterior teeth erupt; and
(C)Pseudo intrusion
Labial tipping of the anteriors around the centroid

Relative Intrusion
• Can be accomplished with continuous archwires by placing an
exaggerated curve of Spee in the upper archwire and a reverse curve in
the lower archwire.
• With both the 18- and 22-slot appliances, when preliminary alignment
is completed, a 16-mil steel, will be sufficient to complete the leveling.

• A possible alternative is a 16-mil “potato chip” A-NiTi wire, preformed
by the manufacturer with an extremely exaggerated curve.
• The extreme curve needed to generate enough force can lead to
problems if patients miss appointments (i.e., the wire does not failsafe)

• In patients those who have little if any growth remaining, an archwire
heavier than 16-mil steel is needed to complete the leveling.
• With 22-slot appliance, 18-mil archwire is used.
• With 18-slot, leave the 16-mil wire in place and add an auxiliary
leveling arch of 17 × 25 mil TMA or steel, tied anteriorly beneath the
base arch.

• Although the auxiliary leveling arch looks like an intrusion arch, it
differs in two important ways:
• the presence of a continuous base arch and
• the higher amount of force.
• Leveling will occur almost totally by extrusion as long as a continuous
rather than segmented wire is in the bracket slots, and segmenting the
arch makes intrusion possible.
• In the maxillary arch, however, a rectangular wire with an accentuated
curve of Spee would be quite acceptable if lingual root torque of the
upper incisors is needed.

Intrusion
• The key to successful intrusion is ‘light continuous force’ directed
toward the tooth apex.
• Can be accomplished in three ways:
(1) with continuous archwires that bypass the premolar (and frequently
the canine) teeth,
(2) with segmented archwires and an auxiliary depressing arch, and
(3) with aligners that have attachments on the posterior teeth.

Bypass Archwires
• Most useful for patients who are in either the mixed or early
permanent dentition period.
• Three different mechanical arrangements are commonly used, each
based on the same mechanical principle: uprighting and distal tipping
of the molars, pitted against intrusion of the incisors.
• A classic version of this approach was seen in the first stage of the
Begg technique in which the premolar teeth were bypassed and only a
loose tie was made to the canine.

• The same effect can be produced by using the edgewise appliance, if
the premolars and canines are bypassed with a 2 × 4 appliance (only
two molars and four incisors included in the appliance setup) or if
brackets on premolars simply do not have the main archwire tied in.

• Ricketts’ utility arch:
formed from rectangular wire; can be placed into the brackets with
slight labial root torque to control the inclination of the incisors as
they move labially while intruding.
• Successful use of any type of bypass arch for leveling requires keeping
the forces light, accomplished by selecting a small-diameter archwire,
and by using a long span ie. b/n the 1st molars and the incisors.

• Wire heavier than 16-mil steel should not be used, and a relatively soft
16 × 16 cobalt–chromium wire is recommended for utility arches to
prevent heavy forces from being developed.
• A more modern recommendation would be 16 × 22 β-Ti wire.
• Whether an 18- or 22-slot appliance is used, the bypass arch should not
be stiffer than 16-mil steel.

• Two weaknesses of the bypass arch systems limit the
amount of true intrusion that can be obtained:
• Except for some applications of the utility arch, only
the 1st molar is available as anchorage.
• The intrusive force against the incisors is applied
anterior to the center of resistance, and therefore the
incisors tend to tip forward as they intrude

• Tying an intrusion arch distal to the midline (b/n the lateral incisor
and canine) moves the line of force more posteriorly and closer to
the center of resistance eliminates the moment that causes facial
tipping of the teeth as they intrude.

• An anchor bend at the molar in a bypass arch creates a space-closing
effect that somewhat restrains forward incisor movement, but this also
tends to bring the molar forward, straining the posterior anchorage.

BURSTONE’S SEGMENTAL ARCH:
• Triple tube molar attachments are used
• Heavy stainless steel anterior segment (0.021x0.025 ss) with TMA tip
back springs (0.017x0.025) and
• Passive segmented posterior stabilizing units (0.019x0.025) are placed.

K-SIR ARCH
• Simultaneous intrusion and retraction of the six anterior by using non-
frictional loop mechanics, which was developed by Dr. Varun Kalra,
based on space closure mechanics advocated by Dr. C. J. Burstone.
• A continuous 0.19" x 0.25" TMA archwire with closed 7mm x 2mm U-
loops at extraction sites.

• 90˚ V-bend is placed in the archwire at the level of each U-loop by
placing Centered V – bends which create two equal and opposite
moments.
• A 60˚ V-bend located posterior to the center of inter bracket distance
to augments molar anchorage during intrusion of anterior teeth.
• And 20˚ antirotation bends are placed to prevent molar rotations.
• 0.019" x 0.025" TMA provides sufficient strength to resist distortion,
but enough stiffness to generate required moments.
• At the same time TMA has low forces, low load deflection rate and
high range of activation

CONNECTICUT INTRUSION ARCH
• Fabricated from a nickel titanium alloy to provide the advantages of
shape memory, springback, and light, continuous force distribution.
• It incorporates the characteristics of the utility arch as well as those of
the conventional intrusion arch.
• It is preformed with the appropriate bends necessary for easy insertion
and use.

• Two wire sizes are available: .016" X .022" and .017" X .025".
• The maxillary and mandibular versions have anterior dimensions of
34mm and 28mm, respectively.
• Although in most cases the wire is not directly ligated into the bracket
slots, the anterior wire dimension is adequate to allow for it.

Segmented Archwires for Intrusion
• This approach is recommended for maximum control of the anterior
and posterior segments.
• After preliminary alignment, a full-dimension rectangular archwire is
placed in the bracket slots of teeth in the buccal segment connecting
them into a solid unit.
• In addition, a heavy lingual arch (36-mil round or 32 × 32 rectangular
steel wire) is used.

• For intrusion, an auxiliary rectangular arch is used to apply force
against the anterior segment.
• The auxiliary tube should be 18 × 25.
• In it, 17 × 25 steel wire with a 2½ -turn helix or 17 × 25 TMA wire
works well.
• If the auxiliary tube is 22 × 28, 19 × 25 TMA wire without a helix or a
preformed M-NiTi intrusion arch is acceptable, but the range of light
force is lower.

• This auxiliary arch is adjusted so that it lies gingival to the incisor
teeth when passive and applies a light force (~10 gm per tooth,
depending on root size) when it is brought up beneath the brackets. and
tied underneath or in front of them.
• An auxiliary intrusion arch can be placed while a light resilient
anterior segment is being used for alignment, but usually it is better to
wait until a heavier anterior segment wire has been installed.

• Full-dimension braided rectangular steel wire or a rectangular TMA
wire is usually the best choice for the anterior segment while active
intrusion with an auxiliary arch is being carried out.
• Two strategies can be used to prevent forward movement of the
incisors as they are intruded:
• Creating a space-closing force by tying the auxiliary arch back
against the posterior segments.
• Tying the depressing arch distal to the midline, b/n the central
and lateral or distal to the laterals

(C) Intrusion arch tied in the midline as only the central incisors are intruded, so that the incisors will
tip facially as they intrude.
(D) In the same patient later, an intrusion arch now is tied between the central and lateral incisors to
intrude all four incisors while reducing the amount of facial tipping.

• With careful attention to appropriate forces and moments with this
approach, approximately four times as much incisor intrusion as molar
extrusion in nongrowing adults is possible
• To intrude asymmetrically, adjust the teeth that are placed in
stabilizing and intrusion segments and tie the auxiliary intrusion arch
in the area where intrusion is required.
• If intrusion is desired on only one side, either a cantilevered auxiliary
wire extending from one molar or a molar-to-molar auxiliary arch can
be used.

Intrusion using TADs
• Many patients with present with moderate to deep bites requiring pure
intrusion of the anterior teeth to level the occlusal plane.
• Unless the deep bite is so extreme that absolute anchorage is needed, it
may be inadvisable to place miniscrews simultaneously in both arches
in young patients.
• In these instances miniscrews can be used to reinforce conventional
orthodontic mechanics.

1) Bilateral implants for en-masse intrusion of anteriors:
• The implants used are 1.3 mm in diameter and 8 mm in length.
• Bone contacts at insertion influences the primary stability of the
implants.
• Increasing the diameter and length of the implant allows greater
surface area contact between the bone and implant.
• It’s important to have a mechanical interdigitation between implants
and cortical bone

Placement Site:
• the alveolar bone between lateral incisor and canine bilaterally at the
level of attached gingiva

Clinical set up
1. The maxillary dental anterior segment should extend from distal of
canines on either side.
A 21x 25 stainless steel arch is placed in all the three segments.
In the anterior segment, hooks are placed between lateral incisor and
canine bilaterally.
This is followed by placement of mini implants which are loaded
immediately.

2. A calibrated Dontrix gauge is used to measure the amount of
intrusive force being applied.
45 gms of intrusive force is applied per side using a pre-stretched
elastic chain i.e. a total of 90 gms of intrusive force is applied to the six
anterior teeth.
3. A ligature wire lace back is tied extending from the maxillary molar
hook to the tag incorporated distal to canine in the anterior segment.

• True intrusion takes place when forces are directed through the center
of resistance.
• If the intrusive force is applied anterior to the center of resistance of a
segment, it results in flaring of the teeth.
• The implants are placed between the canine and the lateral incisors
bilaterally so the point of application of force is closer to the center of
resistance of anterior segment.

• However, directing the force through the center of resistance is not
possible in a clinical set up.
• As a result some amount of flaring is inevitable with any intrusive
mechanics.
• To prevent a steel ligature lace back from the molar hook to distal of
canine should be placed.
• This is just enough to prevent flaring, without having any reciprocal
mesializing effects on the molars and also directs the resultant force
vector close to the center of resistance.

2) Mid-implant for intrusion of maxillary incisors
• The implants used are 1.3 mm in diameter and 8 mm in length.
• A stainless steel archwire with utility design engaging four incisors and
two molar, bypassing the canine and premolar is used made of
0.017x0.025
• Passive segmented posterior stabilizing unit (0.019x0.025)
• A closed coil spring or a E-chain can be used to deliver force of around
60-70 grams

• There are certain cases where only incisors are extruded and need
intrusion or a clinical situation where the canines have been retracted
and the incisors need intrusion, in such cases a mid-implant below the
anterior nasal spine is placed.

• Creekmore T D and Eklund published a case report was using a
vitallium implant for anchorage while intruding the upper anterior
teeth.
• The vitallium screw was inserted just below the anterior nasal spine
and after a healing period of 10 days, an elastic thread was tied from
the head of the screw to the archwire. .

• Ohnishi et al described the correction of significant deep bites using
mini-implants as anchorage for the intrusion of the upper anterior
segment.
• Miniimplants were placed in between the roots of maxillary central
incisors
• Kim et al presented a case report wherein they corrected a Class II,
Div. 2 deep bite malocclusions by using a mini-implant placed below
the anterior nasal spine.
• 4mm of incisor intrusion was achieved in 6 months

Vertical maxillary excess
GROWING
PATIENT
High pull
headgear with or
without maxillary
splint
Vertical pull chin
cup with bite
blocks
NON GROWING
PATIENT
Orthognathic
surgery
Orthodontically /
using mini
implants

High pull headgear
• Restrains growth of the maxilla with extraoral force
• In a growing patient, headgear must be worn regularly for at least 10
to 12 hours per day to be effective in controlling growth.
• The current recommendation is a force of 12 to 16 ounces (350 to 450
gm) per side.
• When the force is applied anterior to the key ridge;
counter clockwise rotation
• When force is applied along the Cres; translation
• When distal to the Cres, clockwise rotation of the maxilla

Vertical pull chin cup with bite blocks
• Vertical pull chin cup with headgear produces significant favorable
skeletal and dental alterations by inhibiting maxillary molar eruption
and descent of maxilla and redirecting mandibular growth in a more
horizontal direction.
It provides:
1. Decreased gonial angle
2. Redirection of condylar growth
3. Increased posterior height.

Extractions and space closure mechanics:
• Extraction site : Suggested that extraction be considered with the
purpose of protracting the posterior teeth in to the extraction site,
thereby allowing the mandible to auto rotate.
• Mechanics of space closure : Should avoid extrusion of the posterior
teeth.
• Avoid running Class II elastics which extrude the posterior teeth.

• Normal horizontal chains or coil springs used , while the teeth are
engaged on a light wire do not apply defined moment to force ratio,
hence result in tipping of the teeth into the extraction site.
• Implant assisted retraction and intrusion

Surgical correction
• Maxillary impaction with or without
genioplasty
• Surgery, comprising total or segmental
maxillary osteotomy, can improve the relation
between the maxillary arcade and the upper
lip
• Lefort I osteotomy is usually performed,
consisting in mobilizing the entire maxillary
plate by resecting a band of bone tissue so as
to achieve maxillary intrusion.

Conclusion
• Although moderate gummy smile can be quite acceptable and
esthetically pleasing if the gum is healthy, more pronounced cases are
less well tolerated and require treatment.
• When gummy smile is basically due to strong vertical alveolar growth
at the incisors, isolated orthodontic treatment can provide satisfactory
results, especially with the development of bone anchorages, extending
the potential of classic orthodontics.

• Maxillofacial surgery, however, is indispensable when etiology is basal,
related to excessive vertical growth of the maxilla as a whole.
• According to the type of treatment, esthetic, dento-alveolar and
skeletal consequences differ.
• It is therefore essential to set treatment objectives in agreement with
patient expectations as of the first examination, so as to select the most
appropriate form of treatment.

References
• William R proffit. Contemporary orthodontics,6th edition
• Proffit, white & sarver.Contemporary treatment of dentofacial deformities .
• Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91–
100
• Orthodontic treatment of gummy smile by using mini-implants : Treatment
of vertical growth of upper anterior dentoalveolar complex. Tae-Woo Kim,
Benedito Viana Freitas.Dental Press J. Orthod. 2010.
• J Williams Robbins. Differential diagnosis and treatment of excessive
gingival display;Pract Periodont Aesthet Dent 1999;11(2).

• Arthur Dolt, J William Robbins.Altered Passive eruption:an etiology of
short clinical crowns. QUINTESSENCE INTERNATIONAL 1997
• Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed
passive eruption of the dentogingival junction in the adult. Alpha Omegan
1977;70:24–28.
• Eliminating a Gummy Smile with Surgical Lip Repositioning. Simon,
Rosenblatt, Dorfman, The Journal of Cosmetic Dentistry •
• Botulinum toxin type A in the treatment of excessive gingival display. Mario
Polo, AJODO

Management of Gummy smile

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