Gummy smile

Gummy smile, Problem and management (orthodontic, surgical, botox case reports)

1. Presented By : Yasmine M. Hammad Under Supervision of: Prof. Dr. Maher A. Fouda

2. Smile types Definition Etiology Case Reports Treatment options

3. Definition: A condition in which gingival tissue is located more  on  the cervical   thi r d  of  the crowns  than  is normal , resulting  in teeth   that  appear shorter  and “gummy.” Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc . A condition characterized by excessive exposure of maxillary gingiva during smiling also called “ high smile line” or “ gingival smile line”. Matthews TG. The anatomy of a smile. J Prosthet Dent 39: 128- 134, 1978 Oliveira, et al . defined ‘gummy smile’ as a continuous band of gingival display of more than 3 mm, during spontaneous smile. Oliveira, et al. Gummy smile: A contemporary and multidisciplinary overview. Dental Hypothesis. 2013 , 4 : 2.55-60 However , “Gummy smile” is considered a descriptive term and not a diagnosis . 

4. Smile Type: Incisor and Gingival Display Lip coverage of the maxillary incisors in full smiles is generally distinguished into three types : low, average, and high smiles . The average smile that reveals 75% to 100% of the upper incisors and is t he most frequent type (found in about 70% of the young adult population ). The low smile displays less than 75% of the maxillary incisors in a full smile and is found in about 20% of the population . The high smile reveals the complete cervico - incisal length of the upper incisors and a contiguous band of gingiva and occurs in about 10 % of the U.S. population. A fourth type of lip line height may be defined as a “gummy” smile, which occurs when patients show more than 4-mm of gingiva on smiling. A Research conducted by Kokich Jr. et al. found that gingival exposure of 4mm on smiling, is considered unesthetic - by both clinicians and lay people-. Nanda R., ESTHETICS And BIOMECHANICS In ORTHODONTICS Second Edition 2015. PART 1 Diagnosis and Esthetic Concepts Chapter 3: Esthetics in Tooth Display and Smile Design. Bjórn U. Zachrisson .

5. *Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60)

6. Hunt et al studied the influence of maxillary gingival exposure on dental attractiveness and found that the attractiveness of a person’s smile is influenced by the amount of maxillary gingival exposure. More attractive ratings were awarded to those smiles where the amount of gingival exposure was within the range of 0–2 mm. Hunt O. et al. The influence of maxillary gingival exposure on dental attractiveness ratings. European Journal of Orthodontics 24 (2002) 199–204 zer0 mm 1 mm 2 mm

7. The NORMAL amount of gingiva showing in a normal full smile is 1-2mm. Upper lip coverage will always increase with age and therefore the percentage of high smiles may be greater among younger age groups and smaller among older adults. There is also a sexual dimorphism in that low smile lines are predominantly a male characteristic and high smiles are predominantly a female characteristic. It is clinically relevant that Gummy smiles are self-corrected to a certain extent over time, especially in men. Age changes in vertical incisor display with relaxed lips, demonstrated by a female patient aged 25 years and 65 years Smile height is influenced by sex and age . - Máyra Reis Seixas et al. Dental Press J Orthod .2011;16(2): 131-57 - Nanda R., ESTHETICS And BIOMECHANICS In ORTHODONTICS Second Edition 2015. - Londoño MA, Botero P. The smile and its dimensions. Rev Fac Odontol Univ Antioq 2012; 23(2): 353-365 .

8. * Quoted from : Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60)

9. The sexual dimorphism in anterior tooth display implies that females have significantly more maxillary and less mandibular tooth exposure than males at all ages. In a group of adults, Vig and Brundo found almost twice as much maxillary anterior tooth display with the lips at rest in women (3.4-mm) as in men (1.9-mm). Men displayed much more of the mandibular incisors (1.2-mm compared to 0.5-mm). The incidence of excessive gingival display ( EGD) is observed in 10% of individuals occuring 14% in females and 7% in males . This situation tends to improve with age, People tend to associate such a smile with a feminized character. Although it does not constitute a real esthetic criterion , it still remains as a sign of youth . However, exposition of2–3 mm is not considered as a gummy smile . Gender differences and the nature of a high smile line: 1- Monaco A. et al Gummy smile: clinical parameters useful for diagnosis and therapeutical approach . J Clin Pediatr Dent.2004 Fall;29(1):19-25 2- André P. Saadoun.Esthetic Soft Tissue Management of Teeth and Implants. 2013 by John Wiley & Sons 3- BJORN U. ZACHRISSON. Esthetic Factors Involved in Anterior Tooth Display and the Smile: Vertical Dimension 32 :07 :(432-445 ) 1998 .

10.  High smile line could be dento -gingival , connected to an abnormal dental eruption, which is revealed by a short clinic crown; muscular , caused by an hyperactivity of the elevator muscle of the upper lip; dento -alveolar (skeletal ), due to an excessive protuberance or vertical growth of the jawbone (maxillary); lastly, a mixed nature , in the presence of more than one of the above described factors The diagnosis of gummy smile must be precocious and based, with reference to specific parameters, upon a careful analysis of the etiopathogenetic factors and the degree of seriousness of the alteration.

11. Etiology of Gummy Smile (GS): Excessive overgrowth of gum tissue due to medications or orthodontic treatment or abnormal eruption of the teeth. The Muscle of the upper lip is hyperactive. Excessive growth of the Maxillary Jaw bone. Inflammation of the gum due to gum disease or bad restoration. Congenital Gingival enlargement. - Claude G. Ibbott . Lip Positioning Surgery for “Gummy Smile”/Thin Upper Lip/Asymmetrical Smile: A Case Report. Oral Health online journal. October 1, 2014  - Nanda R., ESTHETICS And BIOMECHANICS In ORTHODONTICS Second Edition 2015. Chapter 3: Esthetics in Tooth Display and Smile Design. - Máyra Reis Seixas et al. Dental Press J Orthod .2011;16(2):131-57

12. Etiology of Gummy Smile (GS): The fourth type of lip line which is widely known as “gummy smile” show more than 4-mm of maxillary gingiva in full smiling. Its biological mechanism appears to involve the combined effects of anterior vertical excess, an increased muscular capacity to raise the upper lip in smiling , short upper lip , and associated factors such as excessive inter-labial gap at rest and excessive overjet and overbite. Hyperfunction of the lip elevator muscles often results in excessive gingival display (EGD) and is the primary factor when lip length is normal and the lower third of the face is proportional to the other thirds . Delayed eruption as a cause of excessive gingival display and its treatment by esthetic crown lengthening are well documented. Soft and hard tissue resection is an effective method to restore normal tooth dimensions and dentogingival relationships. Jaw deformities can also cause excessive gingival display and require orthognathic surgery. However, in most cases, some or all of these factors are correlated. Thus requiring complex treatment . Orthodontists seem to be the professionals most qualified to critically assess the weight of each of these factors . - Claude G. Ibbott . Lip Positioning Surgery for “Gummy Smile”/Thin Upper Lip/Asymmetrical Smile: A Case Report. Oral Health online journal. October 1, 2014  - Nanda R., ESTHETICS And BIOMECHANICS In ORTHODONTICS Second Edition 2015. Chapter 3: Esthetics in Tooth Display and Smile Design. - Máyra Reis Seixas et al. Dental Press J Orthod .2011;16(2):131-57

13. Checklist of esthetic features to consider in diagnosing and treating excessive gingival display (gummy smile ) Máyra Reis Seixas et al. Dental Press J Orthod .2011;16(2 ):131-57 Despite the etiologic factors involved in the gummy smile, some issues should be necessarily considered during clinical evaluation.Systematic recording of: ( A ) interlabial distance at rest. ( B ) exposure of upper incisors during rest and speech. ( C ) smile arc. ( D ) width/length ratio of maxillary incisors. ( E ) morphofunctional characteristics of the upper lip by means of a checklist. These records are very useful in the diagnostic stage. By including these data in the orthodontic consultation file one ensures that information key to the treatment plan are not forgotten or overlooked.

14. 1. Interlabial distance at rest. I t is crucial that orthodontists include a photograph showing the patient’s lips at rest in the initial orthodontic records. A video footage can also prove useful. There is no direct relationship between GS and amount of interlabial space at rest. Contrary to a long-standing belief, patients with normal upper lip length and reduced inter-labial space can present with excessive gingival display on smiling. When inter-labial space at rest is normal ( 1-3mm ), GS is considered to have a predominantly muscular origin.

15. Usually , the main cause of increased interlabial space is dentoskeletal disharmony (vertical maxillary excess and/or protrusion of upper incisors), which may or may not be associated with anatomical and/or functional changes in the upper lip . (Fig4) Diagnosing GS’s muscular etiology is crucial for immediately recognizing the limitations of orthodontic treatment and seeking help from other specialties such as, for example, esthetic medicine.

16. 2. Upper incisor exposure during rest and speech It is known that when the lips are at rest the amount of exposure of the upper incisors is approximately 2 to 4.5 mm in women and 1 to 3mm in men (Fig 5). This characteristic is directly related to the youthful appearance of the smile and it is expected to decline throughout life ( given the lengthening of the upper lip that results from the process of tissue maturation and aging ). To keep a record of this condition, one can use a standard lateral cephalometric radiograph of the lips at rest and measure the distance in millimeters between the incisal edge of the maxillary central incisor and the lower contour of the upper lip .

17. 2. Upper incisor exposure during rest and speech The following factors are related to increased exposure of the upper incisors at rest: Upper incisor extrusion , dolichocephalic facial pattern, vertical maxillary excess and a short upper lip. When treatment planning involves maxillary impaction and/or intrusion of antero -superior teeth, the magnitude of dentoskeletal change should not be based on the amount of gingival display one wishes to decrease, but rather on the degree of incisor exposure (at rest) that one wishes to maintain.

18. 3. Smile arc The term smile arc is defined as the curvature formed by the incisal edges of antero -superior teeth. To be considered an esthetic and youthful smile, this curvature must be parallel to the superior margin of the lower lip (Fig 7A ). Women’s smiles feature a sharper curvature, whilst in men the curvature appears more flat. In individuals with brachy -cephalic facial pattern, the smile arc is flatter than in meso - and dolichocephalic individuals. In some patients with GS maxillary incisor intrusion can be performed. However, failure to assess the smile arc can result in inappropriate flattening of its curvature, rendering it less attractive.

19. 4. Width/length ratio of maxillary incisors Cosmetic dentistry provides pertinent information regarding tooth proportions and morphology. According to some authors, it is of paramount importance that smile proportions conform to the face. The ratio known as “gold standard” determines that the width of the maxillary incisors should be approximately 80% of its length (Fig 8 ),with acceptable variations between 65% and 85 %,whereas for upper lateral incisors that same ratio should be around 70 %.

20. A ) Reduction in height of the incisal edges of upper teeth by friction and/or fracture . These cases could be treated by: Clinical crown lengthening surgery with osteotomy. (Fig.9) Orthodontic intrusion and subsequent restoration of tooth proportions using restorative dentistry procedures. (Fig. 10) B ) Gingival overgrowth. The etiologic factors behind gingival overgrowth are diverse, ranging from tissue hypertrophy due to infection and/or medication, to altered passive eruption. Crown lengthening is performed by removing excess gingival tissue overlying the cervical enamel. In subjects with GS, it is important to assess whether the crowns of anterior teeth appear very short . If this is the case, the next step is to establish the reason for such shortness, which may occur primarily for two reasons:

21. 5. Morphofunctional characteristics of the upper lip I nclude assessment of: Length, thickness and insertion, direction and contraction of various lip-related muscle fibers is important before taking surgical /or intrusion decision. It may seem that individuals with a short upper lip display more gingiva when smiling, but lip length is probably not directly related to a gummy smile . As regards length, the average value for men’s upper lip is 24 mm and for women, 20 mm. To assess upper lip length one needs to measure the height of the philtrum and labial commissures . Philtrum height is reflected inthe distance between the subnasale ( Sn ) and Stomion (St) points of the upper lip. In turn, commissure height is obtained by measuring perpendicularly the distance between these structures (C1 and C2) and their projections(C1’and C2’) in a horizontal line that joins the two wing bases. Long lip Short lip

22. Thin lips are also known to exhibit greater strain and responsiveness both to dentoalveolar changes and to the contractile pattern of the muscles . Upper lip mobility, which results from the action of specific muscles, seems to be the main feature to consider in evaluating the soft tissues involved in smiling . In addition to the muscle that surrounds the lips internally ( orbicularis oris ), several other muscle groups influence upper lip movement.(Fig.14)

23. Smile takes shape in two stages: In the first ( voluntary smile ) the upper lip is elevated towards the nasolabial sulcus by contraction of the levator muscles, which originate from this sulcus and are inserted into the lips. The medial bundles elevate the lip in the region of the anterior teeth, and the lateral bundles in the region of the posterior teeth until they meet with resistance from the adipose tissue in the cheeks . The second stage ( spontaneous smile ) starts with a higher elevation of both the lips and the nasolabial sulcus through the agency of three muscle groups: The upper lip levator , which originates from the infraorbital region , the zygomatic major muscle and the superior fibers of the buccinator muscle (Fig 13 ).

24. A Case Report Using the chick list: The patient, a 13-year-old girl, reported as chief complaint the reduced size of her maxillary incisors and presented with the following characteristics: Facial thirds with balanced proportions, slightly convex profile, mild mandibular retrusion , competent lip seal, moderate GS, Angle Class I malocclusion with slight extrusion of upper incisors and excessive overbite.

25. Checklist assessment revealed interlabial space , exposure of upper incisors at rest and normal morphofunctional upper lip, as well as appropriate smile arc curvature. A low width/length ratio of maxillary incisors was the only feature assessed as unfavorable. Initial periodontal probing of these teeth showed increased values of gingival sulcus depth, suggesting a state of altered passive eruption.

26. Orthodontic treatment was performed without extraction and, after further probing during the finishing phase, gingivectomy was indicated across the entire anterosuperior region ( Fig18 ). This procedure achieved a better width/length ratio of maxillary incisors and reduced gingival display (Figs 19 and 20).

27. The patient’s smile benefited from increased aesthetics and improved dental proportions, preserving incisor exposure at rest and a pleasant smile arc curvature (Fig. 20 – 21)

28. Summary of Etiology E tiological factors can be divided into dental, gingival, bony, and muscular etiology. This figure shows a diagram representing the sequence proposed for the evaluation of multifactorial gummy smile. On step 1 , the presence of the gummy smile is evaluated. On step 2 , a clinical occlusal analysis is performed (overbite). On step 3 , a gingival excess is analyzed ( a disproportionate crown width and height and gingival excess). On step 4 , the bone structure is examined through cephalometric analysis. On step 5 ,the muscle analysis is conducted (a) lip length (in lateral pictures ); (b) muscle tone (in direct front view ).

29. Treatment options: Excessive gingival display can be managed by a variety of treatment modalities, depending on the specific diagnosis. Orthodontic : Severe gummy smile can be treated with miniscrews through intrusion of the upper incisors. Surgical: A/ Hard tissue: Orthognathic surgery involving maxillary superior repositioning surgery ( Leforte I osteotomy). B/ Soft tissue: Management of excessive gingival display with a lip-repositioning procedure. This is accomplished by removing a strip of mucosa from the maxillary buccal vestibule , then suturing the lip mucosa to the mucogingival line. This results in a narrower vestibule and restricted muscle pull, thereby reducing gingival display during smiling. Esthetic: - Crown lengthening by gingivectomy /and dental restoration. - Botulinum toxin “Botox” injection (transient ).

30. Vertical Maxillary Excess ( VME) management at different ages. The treatment modality to correct vertical maxillary excess is by using a high pull head gear with or without maxillary splint in growing patient and orthognathic surgery in non growing patients. Usage of mini implants is also another alternative in such patients . David R. Musich et al. 1996 conducted a study to evaluate the results of surgical correction of VME in young patients. They found that the vertical growth of the maxilla will continue after surgery in the same proportion as before the surgery, but the postoperative occlusal outcome will probably be preserved. The facial growth vector will continue downwards and backwards. Therfore , Le Fort I osteotomy is not recommended as it may compromise the anteroposterior growth of the maxilla. Nadeer T. et al. Maxillary Growth Control with High Pull Headgear. International Journal of Oral Health Dentistry, April-June, 2015;1(2): 105-107 . Center of resistance of the Maxilla

31. Classification of Vertical Maxillary Excess: Different treatment alternatives depend on the level of excess or the severity of the problem.   It usually requires the intervention of several specialties. The solution could be achieved with an orthodontic approach alone, or in combination with periodontal therapy and restorative dentistry in case of level I vertical maxillary excess. If severity of the vertical maxillary excess increases to level II , it is, between 4 and 8 mm of gum display, besides the aforementioned therapies it would require the intervention of maxillofacial surgery with maxillary impaction. Finally, when vertical maxillary excess surpasses 8 mm of gum display ( level III ), the initial approach would be orthognathic surgery and then, if necessary, a combination of other specialties (orthodontics, periodontics, and dental rehabilitation) Londoño MA, Botero P. The smile and its dimensions. Rev Fac Odontol Univ Antioq 2012; 23(2): 353-365.

32. Meticulous diagnosis of the gummy smile main cause is paramount in setting a proper treatment p lan. If a gummy smile is characterized by overgrowth of anterior vertical maxillary excess , the outcome may not always be successful with conventional orthodontic therapy alone . In such cases, surgical therapy , such as that provided by a Le Fort impaction or maxillary gingivectomies , are often chosen to gain a good smile . If the patients are unwilling to undergo surgical treatment, an alternative method must be considered to treat the gummy smile. Miniplates and miniscrews are now frequently used for establishing absolute anchorage for orthodontic tooth movement .

33. Treatment alternatives include various combinations of orthodontic, periodontal, and surgical therapy. The differential diagnosis should take into consideration both the amount of maxillary incisor display at rest position of the lips and the amount of gingiva shown on smiling . If the maxillary incisor show at rest is optimal, active upper incisor intrusion should not be initiated . Instead, local gingivectomies or surgical crown lengthening with removal of crestal alveolar bone should be done. Such procedures are particularly indicated in cases with altered passive eruption, excessive marginal gingivae, and short clinical crowns, since they will expose more of the anatomic crowns. When crestal alveolar bone is removed during surgical crown lengthening, the gingival margin will stabilize within 6 months at about 3-mm from the new bone level. Attempts to inject botulinum toxin (Botox) for neuromuscular correction of excessively gummy smiles caused by hyper-functional upper lip elevator muscles have been reported to be effective for about 6 months which is considered transitory. Nanda R., ESTHETICS And BIOMECHANICS In ORTHODONTICS Second Edition 2015. PART 1 Diagnosis and Esthetic Concepts Chapter 3: Esthetics in Tooth Display and Smile Design. Bjórn U. Zachrisson .

34. Crown Lenghtening?? * Quoted from : Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60)

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36. * Quoted from : Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60)

37. Treatment options summary: If gummy smile is present with proportional vertical lower third of face and normal lip length , Botox / Lip repositioning / crown lengthening . If gummy smile due to vertical maxillary excess (VME): Adult ( Non-growing): Leforte I osteotomy with orthodontic treatment / orthodontic intrusion using miniscrew . (associated with soft tissue manipulation if needed) Young (Growing): High pull head gear with or without maxillary splint . ( followed by fixed orthodontics / soft tissue manipulation if needed)

38. Orthognathic surgery in cases of excessive vertical growth . Orthodontic mechanics associated with intrusive mini implants in cases of overbite with extrusion of upper anterior teeth , and additional periodontal surgery to remove excessive gingival tissue and bone volume , resulting from the applied mechanics. Periodontal surgery for cases of excessive gingival display or passive eruption. Surgery of the muscular tissue for cases of short upper lip. Use of Botox or surgery of the muscular tissue for cases of hyper-contraction of elevator muscles of upper lip .

39. The Decision Tree as Quoted from : Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60)

40. Temporary Anchorage Devices And Gummy Smile Mohamed Mahfud Alaty , Libyan Dent J 2015, 5: 20918721 -http://dx.doi.org/10.5542/LDJ.v3i0.15115672 Alaty M.M. conducted a study to assess the usability of temporary anchorage devices (TADs), as anchor units, in the treatment of a gummy smile. The selected cases were subjected to inclusive and exclusive criteria (Table 1). Fifteen subjects, 2men and 13 women, comprised the sample of this study. The average age was22. 5± 2.5 years. Patients who were willing to be included in this study were asked to provide signed informed consent in advance before commencing the treatment. Lateral cephalometric radiographs and cast models were used for the pretreatment analysis.

41. Each reading was taken three times, and the mean value was considered and written down on the patient’s diagnosis sheet . Vertical overlapping of upper incisors over lower incisors was another clinical variable which was measured to estimate: the amount of deep overbite, and the amount of intrusion that can be done without compromising the vertical relation between upper and lower incisors, and without creating a cant in occlusal plane. Clinical Measurements: Measuring the gingival smile line (GSL) in mm. GSL is the distance between the gingival margin of upper central incisors, and the lower marginal line of the upper lip on full smile. Each patient was asked to smile; the distance between the gingival margin of upper central incisors and the lower marginal line of the upper lip was measured using an orthodontic digital caliper (Fig.1).

42. Bonding of the upper and lower arch was done using Roth system.022® for all the cases. Once leveling, alignment and de-rotation were finished, stainless steel archwire (0.019’x0.025 ’) was placed to apply intrusive force; two J-hooks were soldered in the area between upper lateral incisors and upper canines bilaterally, and two crimpable hooks were fixed just distal to upper canines. Two anterior mini screws, 6mm length ( AbsoAnchor ®, 1.2mm tip diameter, 1.3mm neck diameter)were inserted between incisors and upper canines . Posterior mini-screws, 8mm length ( AbsoAnchor ®; SH1614-8, 1.4mm tip diameter, 1.6mm neck diameter) were inserted between maxillary first molars and maxillary second premolars .

43. Results All cases of the study showed improvement in the vertical show of smile. Pretreatment mean value of the gingival smile line was 5.966mm (SD ± 1.274), whereas the mean value of post-intrusion gingival smile line was 1.566 mm (SD ± 1.1). The mean amount of reduction in gingival smile line (GSL) was 4.4 mm. T his amount of reduction was achieved in mean time of 13.133 months from the time of the first archwire placement. Overbite : A noticeable reduction of deep overbite had been achieved. The mean reduction in the percentage of vertical overlapping overbite was 44.933% .The mean percentage of pretreatment overbite of the sample was 75.333% (SD ± 1. 52 %) and it became about 30.4% (SD ± 1.1 %) after the intrusion of upper incisors.

44. CONCLUSION: Gummy smile, which is mainly due to maxillary dentoalveolar over growth, can be treated effectively with intrusion using anterior TADs, particularly in case of divergent face . Anterior and posterior mini-screws are effective mean for an absolute anchorage in treatment of deep over bite and increased overjet . When upper anterior teeth are retracted and intruded at the same time , accurate mount, and precise point of application of intrusive and retrusive orthodontic forces are crucial factors for pure intrusion and bodily translation of upper anterior teeth, without proclination .

45. CASE REPORTS Orthodontic treatment : #1, #2, #3, # 4 , # 5 , # 6, #7 Surgical treatment: #11 Esthetic treatment: #8, #9 & 10, #12

46. Rationale of Orthodontic treatment of ‘Gummy’ smile Dentoalveolar excessive gingival display occurs by overgrowth of the maxillary anterior dentoalveolar heights, but it is difficult to intrude anterior sections with a normal orthodontic device . For this reason, surgical impaction of the maxillary anterior dentoalveolar region is often applied in severe gummy smile cases. However, surgical correction carries potential risks associated with infection, alveolar bone necrosis, and loss of tooth vitality. Moreover, since impaction of the anterior segment by Le Fort I tends to increase nasal alar width, which makes the patient’s nasalprofile worse, we have to decide carefully whether we will apply surgical or nonsurgical treatment. Masato Kaku et al (Angle Orthod . 2012;82:170–177.)

47. Rationale of Orthodontic treatment of ‘Gummy’ smile Masato Kaku et al (Angle Orthod . 2012;82:170–177.) Orthodontic intrusion of maxillary anterior teeth may eliminate the gummy smile in deepbite cases to some degree. Orthodontic tooth movement has always been limited because of insufficient anchorage control. Intraosseous anchorage systems do not require patient cooperation while obtaining pure intrusion.

48. Case # 1: Bimaxillary Protrusion and Gummy Smile Corrected with Extractions, Bone Screws and Crown Lengthening. Chris Lin, Yvonne Wu, Chris Chang, W. Eugene Roberts: Int J Ortho Implantol 2014;35:40-60) A 25 year-old woman presented with a history of non-extraction orthodontic treatment, and a labial frenectomy to close the diastema between the upper centrals, at age 10. the current concerns were bimaxillary protrusion and a gummy smile. Lip incompetence with hyperactive mentalis muscle during lip closure and short clinical crowns were noted. The lower anteriors were mildly crowded.

49. Post Treatment 

50. Wherever you are whatever you do… be in love with what you do !!

51. Case#2 : Mini-screw Application For Gummy Smile Correction Tülin ( Uğur ) TANER2007, 31: 3: 44-51 A 20-year-old female patient was referred to our clinic for orthodontic treatment. Her chief complaint was an excessive overbite and gummy smile. The patient exhibited a straight facial profile with a slightly prominent upper lip .

52. Intraoral photographs showed complete overlapping of mandibular incisors by extruded maxillary incisors. Molar and canine relationship was Class I on the right side and Class II on the left side. The mandibular midline shifted 2 mm to the left side relative to the maxillary and facial midlines. The arch length discrepancy was -1.5 mm for the upper and lower dental arches. The upper central incisors and canines had mesial-in rotations.

53. Panoramic radiographs revealed no missing teeth except the upper and lower right third molars. These teeth were extracted before the orthodontic treatment.

54. Lateral cephalometric analysis showed a skeletal Class 2 Division 2 relationship , mandibular retrusion and slightly decreased mandibular plane angle (FMA angle: 23 º). The upper incisors inclined palatally at a 94 º angle relative to the SN plane (U1-SN) and 108 º angle relative to FH plane (U1-FH), and the lower incisors inclined lingually at an 81 º angle relative to the mandibular plane (L1-MP) and a 76 º angle relative to the FH plane (L1-FH). The positions of the upper incisors were extruded relative to the upper lip and functional occlusal plane. Overbite was 8 mm and overjet was 6 mm. The upper and lower lips both were -2 mm relative to the E-line. A temporomandibular joint evaluation showed no signs of clicks or crepitation, and the facial and masticatory muscles were asymptomatic.

55. Treatment objectives The treatment objectives included: (1 ) intruding the upper incisors with mini-screw implants as the orthodontic anchorage. ( 2) obtaining adequate overbite and overjet for a satisfactory maxillary gingival exposure in the smile. ( 3) obtaining Class I molar and canine relationships.

56. Treatment started with a .016X.016 inch NiTi utility arch for alignment and leveling of upper incisors. After that, a segmental .016X.022 stainless steel (SS) archwire was fitted to the upper incisors with a surgical spur at the midpoint of the central incisors . Another day, two mini-screw implants were implanted in the alveolar bone between the roots of the central and lateral incisors bilaterally under local anesthesia. At the same appointment, an 18-mm-sentalloy coil-spring was placed from the implants to the surgical hook . Upper incisors were intruded with an 80 gr of force for 5 months. After intrusion of the incisors, a utility arch was inserted and ligated to the implants for enhancing anchorage while aligning and leveling the posterior teeth with an .016 inch NiTi piggy-back archwire .

57. Alignment and leveling of the lower teeth were accomplished using .016 inch NiTi , .016 SS and.016X.022 inch SS archwires sequentially. At 12months of orthodontic treatment, the mini-screw implants were removed . The removal of miniscrew implants was uneventful . The canine and molar relationships were Class II on the left side at that time. Prolonged use of Class II elastics were not effective. Thus, a Eureka Spring appliance was used to correct the Class II relationship on the left side. Three months after the insertion of the Eureka Spring, Class I molar and canine relationship were achieved. Total treatment time was 28 months. Upper and lower hawley appliances were worn for retention.

58. Upper incisors were intruded successfully and an improvement of the gummy smile could be observed in a posed smile . Class I molar and canine relationships were obtained with adequate amounts of overbite and overjet .

59. The post-treatment lateral cephalometric analysis showed no skeletal changes but changes in incisor inclinations and lip positions. The maxillary incisor inclination was slightly decreased and the mandibular incisor inclination was increased to the normal value. An 8 mm of deep overbite and a 6 mm of overjet was corrected to 2 mm. Upper and lower lips were slightly retracted due to the changes in incisor positions . The significant intrusion of upper incisors was evident on superimpositions of pre- and post-treatment cephalometric films .

60. Conclusion The maxillary incisors achieved remarkable intrusion and alignment with the miniscrew implant anchorage without relying on patient cooperation. There were no side effects and no problems with patient cooperation. Moreover, there was no obvious root resorption , either. This case report demonstrated that the mini-screw implant anchorage method was useful for achieving an excellent improvement of a dental deep bite and gummy smile .

61. Case #3: Gummy smile and facial profile correction using miniscrew anchorage . Masato Kaku et al (Angle Orthod . 2012;82:170–177 .) A female (age: 31 years 1 month ), complained of a gummy smile. We had previously recommended orthodontic treatment with orthognathic surgery . However, the patient was not willing to undergo the surgery. The pretreatment facial photographs showed a convex profile, an acute nasolabial angle, hypermentalis activity with closed lips, and excessive gingival display in smiling. The patient had a dentoalveolar gummy smile and the posterior teeth were in normal vertical positions. In this category, gummy smile can be corrected efficiently by intrusion of maxillary incisors.

62. The intraoral photographs and dental casts revealed a 4.0- mm overjet and a 2.5-mm overbite. The right molar relationship was Class I and the left was full Class II; there was a little crowding in both arches. The lower dental midline coincided with the facial midline, but the upper midline was shifted to the right by 2mm.

63. A panoramic radiograph showed the existence of upper right third molar. As shown in the cephalometric measurements , a skeletal Class II relationship (ANB angle, 6.6u) with labial inclination of lower incisors (IMPA , 109.2u) was evident. Based on this information , the patient was diagnosed with a skeletal Class II maxillary protrusion with a gummy smile. **  Z angle : angle between FH and Z line; Z line, profile line tangent to the chin and the more anterior vermilion border of both lips

64. Treatment Plan: Because the surgical treatment plan was declined by the patient, the treatment objectives essentially consisted of vertical control and distalization of the anterior teeth . The treatment plan involved the following steps: 1. Extraction of all second premolars; 2 . Insertion of miniscrews into the buccal alveolar bone of the mesial part of the first molars; 3 . Distal movement of the upper anterior teeth; 4 . Extraction of the upper left second molar; and 5 . Intrusion of the upper anterior teeth by miniscrews , which were placed above the root apices between the upper lateral incisors and canines. The treatment options were discussed with the patient. The first option was traditional orthodontic treatment with Le Fort I surgery to reduce the gingival exposure and to correct maxillary protrusion. The second option involved orthodontic intrusion of the maxillary anterior region using miniscrew anchorage.

65. The miniscrews were inserted into the buccal alveolar bone between the upper and lower first molars and second premolars . Next, all the upper and lower second premolars were extracted , and 0.018-inch s tandard edgewise brackets were bonded on the upper and lower teeth. The upper first premolars were moved distally from the miniscrews with the use of elastic chain. The lower first premolars were also distalized from the first molars. After 16 months, the upper left second molar was extracted and distalization of first molar began. The upper left first molar was distalized by an open coil spring from the first premolar , which was connected tightly with a miniscrew . Under local anesthesia, two self-drilling titanium alloy miniscrews * (1.6 mm in diameter and 8 mm in length); * Dual Top Auto Screw, Jeil Medical Corp, Seoul, South Korea.

66. After the upper left molar was distalized into a Class I relationship, retraction of the maxillary anterior teeth began. Anterior teeth retraction was carefully conducted using miniscrews to maintain the molar Class I relationship. Then, the intrusion of anterior teeth began with placement of miniscrews (1.6 mm in diameter and 8 mm in length) in the maxillary bone above the root apices between the upper lateral incisors and canines . Generally, miniscrews for intrusion of incisors are placed between the roots of the anterior teeth. In this case, we inserted the miniscrews in the maxillary bone above the root apices because the patient had sufficient space for miniscrew placement superior to the incisor apices.

67. Local anesthesia was administered with approximately 1.0 ml of Lidocaine near the apices of the anterior teeth . The mucosa was cut and exposed bone surface and miniscrews were inserted into the maxillary bone. An 0.018-inch wire that was connected at the miniscrew head was exposed from the suture region, and the flap was closed. After miniscrew insertion , 50 g of intrusive force was applied from each miniscrew to the upper lateral incisors. After 12 months of anterior teeth intrusion , the patient’s gummy smile and overjet were fully corrected.

68. The teeth were well aligned with a good intercuspal relation. The total treatment period with the fixed appliance was 3.5 years. After edgewise brackets, lingual bonded retainers were set on both the upper and lower arches between the premolars. The anterior miniscrews were left in place, and were combined with a clear retainer at night during retention for 16 months (Figure 11 ) -this was effective in preventing the eruption of intruded incisors-, then the miniscrews were removed. The position of the teeth continued to be stable 36 months from the beginning of the retention.

69. Treatment Results A normal overjet and overbite were achieved and the upper and lower midlines coincided . The patient’s profile was improved by correction of overjet using miniscrews . The upper and lower dental arches were well aligned, and a Class I molar relationship was achieved. The strain of the mentalis muscle became more relaxed. The facial profile was significantly improved (Figure 12). The post-treatment panoramic radiograph showed that all of the roots were parallel, and severe root resorption was not observed .

70. On the cephalometric superimposition (pretreatment and post-treatment), the upper anterior teeth and the left first molar were distalized 5 mm (Figure 14). The anterior teeth also showed a 4-mm intrusion . IMPA changed from 109.2uto 92.5u. The ANB angle changed from 6.6u to 5.8u,and the Z-angle also changed from 56.5u to 70.0u(Table 1). Post-treatment facial smile photographs are shown in Figure 15. Gingival exposure post-treatment was dramatically reduced as a result of intrusion of the anterior teeth, and the patient obtained a good smile.

71. Before After

72. Early treatment of incisor crowding 2 lectures by Prof. Dr. Maher Fouda FREE attendance for all doctors Normal development of primary and mixed dentition Thursday 3/11/2016 10:30 am Medical Syndicate club Talkha

73. Meet the stars at Mansoura’s 2 nd international dental congress (MIDC 2016) Only 270 L.E. for all the department students!!

74. Case #4: Correction of a severe gummy smile without surgery Dr. John Graham https://www.orthodontisteenligne.com/en/blog/19364/ A 25 year old woman with previous -2 years- orthodontic treatment was presented. The patient’s chief complaint was that she didn’t like her gummy smile. Upon evaluation, a severe gummy smile; more than 1 cm (10 mm) of gingiva is visible upon smiling. The initial treatment plan included a “maxillary impaction” which is an orthognathic surgery procedure aimed at “moving up” the upper jaw to reduce the gummy smile. Having lost her insurance coverage, the patient  could no longer afford the surgical fee so the initial treatment plan had o be modified.  Dr Graham offered to usetemporary anchorage devices (TADs) to intrude the maxillary dentition and correct the gummy smile.

75.  Although the occlusion and tooth alignment were acceptable at this stage of treatment (transfer), the smile still showed a lot of gingiva because this correction was originally planned to been done surgically. Treatment goals were  still aimed at reducing the excessive gummy smile. The following Orthodontic mechanics were used for the intrusion of the maxillary dentition.

76. Cone Beam Computer Tomography (CBCT) imaging after screw insertion and before treatment initiation. Cone Beam Computer Tomography (CBCT ) Showing i nitial and final stages.

77. Case #5: Camouflage of Severe Skeletal Class II Gummy Smile Patient Treated Nonsurgically with Mini Implants Irfan Qamruddin et al. Case Reports in Dentistry, Volume 2014, Article ID 382367, 7 pages A 16-year-old female patient was presented with a complaint of protrusion along with excessive visibility of upper incisors and excessive display of gums on smiling. dental history revealed her visit to a local general dentist 2 years ago with the same complaint where she was treated by trimming of her incisors to reduce visibility . Extraoral examination displayed a convex profile with mandibular deficiency and slight maxillary protrusion. Nasolabial and mentolabial sulcus were acute. Lips were incompetent , with incisor visibility of 7mm with relaxed lips and gingival display of 6mm on smiling commonly known as “gummy smile .”

78. Intraoral examination revealed full cusp class II molar and class II canine relationship on both sides. The maxillary arch was elliptical in shape with mild spacing while the mandibular arch was square shaped which also showed 7mm crowding in the anterior region. A 100% deep bite and an overjet of 13mmwere noted. Both the maxillaryand mandibular midlines were coinciding with the facial midline . Oral hygiene was poorly maintained which had resulted in gingivitis.

79. Panoramic radiograph revealed no missing teeth and no sign of root resorption . The maxillary and mandibular third molars were in the formative stages. No caries or periapical lesion was visible. Lateral cephalometric analysis showed a skeletal class II relationship with severe mandibular deficiency. Vertical analysis depicted mild hyper-divergence and steep mandibular plane angle. Upper incisors were proclined and extruded beyond the normative mean.

80. Treatment Objectives: The patient was diagnosed to have severe skeletal class II relationship with mandibular deficiency. Dental relationship was Angle’s class II div 1 with anterior maxillary dentoalveolar protrusion in both sagittal and vertical planes which resulted in excessive overjet , overbite, and gummy smile. The desired treatment objectives included : ( 1) intrusion and retraction of upper incisors to attain normal overjet and overbite with competency of lips and esthetically pleasing smile. (2 ) restoration of trimmed maxillary incisors .

81. Ideal treatment plan offered to the patient was the subapical segmental osteotomy in upper jaw to move the whole anterior maxillary segment upward and backward with surgical mandibular advancement in lower jaw. To execute that plan all first premolars in both jaws were to be extracted bilaterally to decompensate the arches so that the case could be finished in class I molar and canine relationship . However the patient rejected the surgical plan ; therefore alternate treatment plan was followed. Objective of alternate treatment plan was extraction of maxillary first premolars with intrusion and retraction of upper anterior segment and non-extraction treatment in lower arch . This will finish the case in class II molar and class I canine relationship. Ideal and Alternate Treatment Plan

82. Treatment Progress: A 0.022 slot preadjusted MBT prescription brackets were bonded. Vertical placement of brackets on central and lateral incisors was kept at the same level to allow restoration of incisal edges after the treatment. Alignment and leveling were achieved by the following sequence: 0.012 Niti , 0.016Niti , 0.017 × 0.025 Niti followed by 0.017 × 0.025-in SS wire. Extractions of upper first premolars and insertion of mini implant -between the roots of upper first molar and second premolar bilaterally- were carried out in the same visit . Implants were loaded immediately with elastomeric chain to retract the canine first into class I relation. Then, a force of 150 gm was applied by NiTi closed coil springs which extended from implants up to the helix formed in the archwire distal to the lateral incisors on both sides .

83. The force vector passed above the CRes of maxilla , so that the anterior teeth were retracted upward and backward. Forces were repeated after every three weeks till the extraction spaces are completely closed. Fixed appliance was removed after 27months and the patient was referred for the restoration of central incisors. After composite restorations, acrylic retainer was given in upper arch and fixed retainer in lower arch

84. Treatment results Remarkable improvement in facial and smile esthetics was accomplished . Patient had competent lips and the visibility of incisors was reduced to 3mm after restoring the incisal edges with composite filling. Smile was broader; smile arc was consonant with 1mm gingival exposure on lateral incisors. Facial convexity was also reduced with the retraction of upper lip and mild autorotation of lower jaw in anticlockwise direction. Nasolabial angle and mentolabial sulcus were improved.

85. Maxillary incisors were retracted by 6mm whereas intrusion attained was 5 mm . Anterior dentoalveolar height was reduced by 5mm while lower anterior dentoalveolar height was reduced by 4 mm . Lower incisors were proclined by 7 ∘ which also reduced the overjet to 2mm and overbite to 20 %

86. Points to consider: Orthognathic surgery is the only ideal treatment when there is severe skeletal discrepancy in adult patient; however, in many societies , surgery is only pursued when there is life threatening condition . Surgical orthodontics is barely accepted by patients for esthetics because of multiple reasons that include financial constraints, fear of procedure, and adverse effects and also on religious grounds! Our patient also refused the surgical option for all the above mentioned reasons . The other option for skeletal malocclusion is dental camouflage which involves repositioning of dentoalveolar structure to disguise the severity of skeletal problem . Class II cases demand either camouflage with extractions of two maxillary and two mandibular premolars or extractions of only upper first premolars when there is no arch length discrepancy in lower arch.

87. NOTES: The Retraction Mechanics. Segmental mechanics by Burstone and three-piece arch by Shroff et al. are an option but both mechanics are indeterminate and anchorage loss may associate. The benefits of using mini implants in this case were twofold: ( i) they provided maximum anchorage to retract maxillary anterior segment ; ( ii) simultaneous retraction and intrusion were possible. Occlusogingival position of mini implant determines the biomechanical effects of the force system. Applied force in this case had two components: horizontal and vertical. Horizontal component resulted in retraction ( r ) while vertical component moved the anterior teeth upward ( i ). However the force vector passed below the center of resistance of anterior teeth; therefore moment was created which also tipped the incisors lingually . Therefore the retraction of incisors in this case involved both the translation and tipping movement, as the inclination of the incisors was improved along with the lingual movement of roots .

88. BEFORE AFTER

89. Treatment of dentoalveolar excess: • Dentoalveolar type- Excessive vertical growth and/or- Protrusion of upper anterior dentoalveolar complex. This dentoalveolar type is a good indication of mini-implant treatment and is classified as follows: V ertical growth of upper anterior dentoalveolar complex . P rotrusion of anterior dentoalveolar complex. P rotrusion of upper anterior dentoalveolar complex and extrusion of upper posterior teeth. Classification of etiology: • Dento -gingival type Deficient gingival recession, which is revealed by a short clinical crown. • Muscular type- Hyperactivity of the elevator muscle of the upper lip. • Short upper lip type- Short philtrum height. • Skeletal type- Vertical maxillary excess.- Maxillary protrusion. Dentoalveolar type- Excessive vertical growth and/or- Protrusion of upper anterior dentoalveolar complex .

90. Case #6: Introduction Cases with excessive vertical growth of upper anterior dentoalveolar complex usually show extrusion and retroclination of upper incisors, deep overbite, and gummy smile .(Fig.1) This kind of case could be treated well with the Burstone’s Segmented Arch Technique.(Fig.2) It would be used “one-piece intrusion arch” for the retroclinated and extruded upper incisors. In this technique, high-pull headgear and precision lingual arch are used to counter act the adverse reactions like extrusion of upper molars . However, the mini-implants mechanics ( Fig.3 ) can treat the retroclined and extruded incisors very efficiently without an extrusion of upper molars and it does not need the patient’s cooperation.

91. Case #6 : Orthodontic treatment of gummy smile by using mini-implants (Part I): Treatment of vertical growth of upper anterior dentoalveolar complex. Kim TW, Freitas BV. Dental Press J. Orthod . Apr. 2010 v . 15, no. 2, p. 42.e1-42.e9 . A Korean Boy ( 10.6 years) was presented with Class II, div 2. and a gummy smile. A non-extraction treatment plan was decided. The gummy smile and deep overbite was planned to be treated with a mini-implant. Twin-blocks were planed for accelerating the mandibular growth.

92. A (1.6 x 6.0 mm) mini-implant ( Jeil Med Co, Seoul, Korea) without drilling was used with a NiTi closed coil spring that was applied immediately over a 0.019 x 0.025-in stainless steel box wire (Figure 3). The mini-implant and the upper portion of NiTi closed coil spring was covered by a flap. The covered mini-implant was not discomfort to patients and it was preferred to a headgear and a lingual or transpalatal arch. After using this mechanics, three cases showed upper incisors that were intruded and proclined (Figure 3B and 4) as one-piece intrusion arch was used.

93. Superimposition of tracings before treatment and after intrusion and proclination of upper incisors . After using mini-implant for 6 months, the upper incisors were intruded and proclined like the movement by one-piece intrusion arch

94. Gummy smile disappeared after debonding . Profile was improved by using Twin-Block. Before After

95. MAXILLARY GROWTH CONTROL WITH HIGH PULL HEADGEAR : Case Report The characteristic finding of increased maxillary growth resulting in vertical maxillary excess can be observed as a gummy smile, an increased lower anterior facial height or increased display of incisors . Excessive growth of the maxilla in children with class II malocclusion has more of vertical than anteroposterior component, and if the maxilla moves downward, the mandible rotates downward and backward The use of headgear dates very long back and has found a variety of clinical application in contemporary orthodontics like distalization , restricting maxillary growth and anchorage control. The force vector should travel through the centre of resistance of the maxilla when we want a bodily movement of the maxilla. The centre of resistance of maxilla exists at the posterior-superior aspect of the zygomatico -maxillary suture.

96. Case #7: MAXILLARY GROWTH CONTROL WITH HIGH PULL HEADGEAR Nadeer T. et al. International Journal of Oral Health Dentistry, April-June, 2015;1(2):105-107 A 10 year old female patient, in her pre-pubertal growth status exhibited a prognathic maxilla, retrognathic mandible with a vertical growth pattern and class II skeletal base. There was an increased incisor exposure at rest and smile with proclined incisors.

97. Treatment Objectives: Restrain the forward and downward descent of the maxilla due to growth. It was decided to treat the patient with are movable high pull head gear splint . The length of the outer bow was kept short so that forces passed through the centre of resistance of the maxilla with a force magnitude of 600 gm per side . The patient was instructed to wear the head gear full time except while eating brushing and bathing. As the patient had potentially incompetent lips, she was also instructed to perform lip exercise by forcefully closing her lips on to the bows . Recall visits were scheduled at 3 weeks interval and force levels were checked and maintained. The force values of the head gear module were measured during each visit and the patient was advised to step up the attachment to the next hole accordingly .

98. After 8 months of full time wear of the appliance (as recommended by Marcotte ) the bite was opened, with a reduction in incisor visibility. The over jet was reduced from 5mm to 3mm.

99. Pre and Post treatment cephalometric tracing showed that growth of the maxilla was restrained. The cephalometric changes showed that the mid face height was reduced by 2 mm (N-ANS). The lower anterior facial height reduced by 5 mm. There was dento -alveolar intrusion as the distance of incisal tip to the palatal plane reduced by 6 mm. The SNA angle improved indicating a reduction in maxillary growth. The SNB angle mildly improved due to forward and upward rotation of mandible, which is also indicated by mild reduction in mandibular plane angle. Pre treatment Post treatment

100. Pre treatment Post Treatment

101. The objective of lip repositioning / Mucosal strip technique is to minimize the gingival display by limiting the retraction of the elevator s mile muscles (eg, zygomaticus minor, levator anguli , orbicularis oris , and levator labii superioris . Lip repositioning Surgery is contra- indicated in cases with: 1- inadequate attached tissue 2- short upper lip. 3- minimal vestibule 4- and excessive VME . Lip repositioning is a simple alternative to other morbid techniques of treating excessive gingival display. The long-term stability is still to be explored . Rationale of Soft tissue Surgical treatment of ‘Gummy’ smile - M. Jananni . Surgical correction of excessive gingival display in class I vertical maxillary excess: Mucosal strip technique. J Nat Sci Biol Med. 2014 Jul-Dec; 5(2): 494–498 - Ari Rosenblatt , Ziv Simon ( Int J Periodontics Restorative Dent 2006;26:433–437.)

102. The incision width should roughly be two times the amount of gingival display . The coronal and apical incisions met in the bicuspid regions in a rounded fashion. The frenum between the two centrals should be left intact as a reference point so the incisions would not extend across the mid-line. The epithelium is then dissected as a partial thickness flap using a mosquito forceps to hold the tissue. The mucosal flap is advanced and sutured at the muco -gingival line using interrupted 5-0 sutures. General guide lines:

103. Case # 8 : Lip Repositioning for Reduction of Excessive Gingival Display:A Clinical Report Ari Rosenblatt, Ziv Simon ( Int J Periodontics Restorative Dent 2006;26:433–437) A 30-year-old woman presented with a chief complaint of a “gummy smile .” Her treatment goal was to minimize gingival display in her smile. clinical examination revealed moderate maxillary gingival display. With an exaggerated smile, the patient’s teeth were visible from the maxillary right first molar to the maxillary left first molar , with 3 to 4 mm of excessive gingival tissue display. The maxillary anterior teeth had normal anatomic proportions . Local anesthetic was administered in the vestibular mucosa and lip from maxillary right to left first molar . A marking pencil was used to outline the incisions on the dried tissues. A partial-thickness incision was made at the mucogingival junction from the right first molar to the left first molar. E pithelium was removed leaving the underlying connective tissue exposed.

104. The parallel incision lines were approximated with interrupted stabilization sutures to ensure proper alignment of the lip midline with the midline of the teeth. Then, a continuous interlocking suture was used to approximate both flap ends. The patient was given appropriate postsurgical instructions and medical prescriptions. The patient reported “ tension” on her upper lip and “slight pain” when smiling for 1 week after surgery The suture line healed in the form of a scar that was not apparent when the patient smiled, because it was concealed in the upper lip mucosa. A follow-up examination 8 months later showed a reduction in the patient’s excessive gingival display. Immediately Post-operative Pre-operative 8 Months Post-operative

105. Case Report #9: Lip Positioning Surgery for “Gummy Smile”/Thin Upper Lip/Asymmetrical Smile: A Case Report October 1, 2014  by Claude G. Ibbott A 53 -year-old female was presented with unattractive high smile line. Intraoral examination revealed excellent periodontal health and excellent restorative dentistry. An adequate vestibule and a good zone of attached gingiva were noted. Her lip length was ( normal), the lower 1/3 of her face was proportional to the other thirds and there were no issues with her occlusal plane. Her smile was asymmetrical and lifting to the right side ( 7mm . gingiva showing on the right and about 5mm to tooth #23 on the left). Her upper lip was thin and stretched. She expressed an interest in showing less gingiva and having a fuller upper lip. She understood that her asymmetry was a genetic trait from her father. A diagnosis of hypermobile upper lip was made. The apical incision on the right side was made 2mm wider than the left side. There was no swelling and little pain with the procedure. She was pleased with the result as the smile is now more symmetrical and the upper lip has appeared to have increased in volume. The result was stable at four months follow-up.

106. This 32-year-old female reported that she has, “hated her smile since she was a young girl”. The only intra-oral issues noted were a rotated right lateral incisor and a retained deciduous tooth upper right segment (Impacted cuspid ). Her main concern was her “gummy smile”. Restorative work to improve the appearance of #12 and the deciduous tooth would be done after the lip surgery. Examination showed a normal lip length and a proportional lower third of the face. Case Report #10

107. Gingival tissues were on enamel and it was determined that crown lengthening would be required before lip surgery. Crown lengthening was done and after only one week of healing, lip surgery was done. The patient had little discomfort and was thrilled with the result Crown lengthening Lip Repositioning

108. Maxillary Surgical repositioning ( Le forte I) Vertical maxillary excess is a clinically recognizable facial morphology, it is manifested primarily by gummy smile, exposure of the maxillary teeth, with incompetent lips. However, certain cephalometric characteristics indicate the need for surgical correction: - increased length of lower facial. - steep mandibular plane angle - increased anterior dento -alveolar height - mostly class II and occasionally class I - Maxillary incisor display >3 mm at rest.

109. Case#11: Orthodontic Surgical Treatment of Gummy Smile with Vertical Maxillary Excess A 32 year adult female patient with a chief complaint of protruding upper front teeth (fig 1) with an excessive exposure of gingiva. Initial examination reveals excess visibility of gingiva at rest and during smiling. Incompetent lip with gap of 12mm suggesting of vertical maxillary excess. She had dolichocephalic, convex profile and posterior divergent and a high lip line with 9 to 10 mm of gingival visibility during smiling. Class I molar and class I canine with overjet of 4mm and overbite of 5mm. Lower midline shifted to left side by 2mm with mild lower anterior crowding.

110. Cephalometric analysis revealed class II skeletal base with bimaxillary protrusion with ANB of 6 degree patient present with average to vertical growth pattern with mandibular plane angle of 30 degree and y-axis of 70 degree(fig 2 ). The upper and lower anteriors were proclined according to Steiner’s analysis. Excessive eruption of upper and lower incisors was noted according to Burstone analysis. This excessive eruption of incisors is seen in patients with vertical maxillary excess in order to partially compensate for the jaw rotation. The vertical maxillary excess, thin alveolar troughs, excessive curve of spee , proclined upper and lower anterior teeth, excessive eruption of upper and lower incisors warranted a surgical line of treatment.

111. Treatment Plan Treatment objectives were: - To improve the positioning of the maxillary arch with a reduction in the gingival exposure on smiling and at rest. - To facilitate autorotation of the mandible. - To match skeletal bases. - To obtain a skeletal class I relation. - To level and align the arches. - To achieve an ideal overjet and overbite. - Correct lip incompetency and achieve an aesthetic profile . A surgical prediction was done and the treatment planned was, extraction of all four first premolars during surgery , mandibular subapical osteotomy to intrude the anterior segment by 5mm, maxillary superior repositioning of 5mm by Le Fort I osteotomy along with anterior segmental osteotomy of the maxilla to setback the anterior alveolar segment by 6mm .

112. First molars were banded and 0.022” preadjusted brackets (MBT Prescription) were bonded to the remaining teeth except all 4 first premolars since they had to be extracted during surgery. A continuous archwire of 0.016” nickel titanium was inserted (Fig3). The archwire size in the maxilla was gradually increased until 0.019X0.025” stainless steel wires were placed in both arches. This resulted in decrease in the maxillary anterior teeth proclination and deepening of the bite. Levelling of anterior segment was planned surgically by intruding the anterior segment because of the thin alveolar trough so as to avoid root resorption

113. After 6 months of presurgical orthodontics (fig 4), surgery was performed. Two splints were fabricated with acrylic (Fig 5). Mandibular subapical osteotomy was carried out to intrude the anterior segment by 5mm, and was followed by Le Forte I osteotomy to superiorly reposition the maxilla by 5mm and anterior segmental osteotomy of the maxilla to setback the anterior alveolar segment by 6mm. the maxilla was positioned superiorly so as to achieve 2 to 3mm of maxillary incisor exposure with the upper lip at rest. Surgeries were performed without any complications and the correction was maintained by rigid fixation ..

114. After completion of post-surgical orthodontics, a demonstrated facial symmetry with proportional facial thirds, a balanced maxillo -mandibular relationship, an aesthetic smile line and good lip positioning . Treatment produced Skeletal class I relation .

115. Superimposition of the pre-treatment and post-surgical cephalometric tracing indicated the amount of setback of the maxillary anterior segment and intrusion of the mandibular anterior segment. It also demonstrated the amount of superior repositioning of the maxilla along with the autorotation of the mandible.

116. BEFORE AFTER

117. BOTOX Dinker S, Anitha A, Sorake A, Kumar K J Int Oral Health 2014;6(1):111-5. Cosmetic surgical procedures like the use of Botulinum toxin type-A, dermal fillers, Orthodontic and Orthognathic procedures, dental bleaching and other dental cosmetic substitutes are widely requested by the adults . The advantages of these procedures are definitive increase in self esteem . However, some of these procedures are more time consuming than the others which can further cause impaired psychological effects especially in adults. The Botulinum toxin type-A injection used for the correction of excessive gingival display caused by hyperactive upper lip elevator muscles, was seen to be highly effective. Extremely satisfactory results are met for both the patients and the orthodontists. Although Botox has a transitory effect, six months post treatment the gummy smile was occasionally reported to be within the normal range. D epending on the cause and the needs of the patient, usage of BOTOX could well be used as an alternative procedure for faster and minimally invasive treatment of gummy smile.

118. Case #12: . Management of gummy smile with Botulinum Toxin Type-A: A case report . Dinker S, Anitha A, Sorake A, Kumar K J Int Oral Health 2014;6(1):111-5 . A 23 year old female patient presented to the clinic with the chief complaint of excessive gingival display. Pre- treatment photographs showed a straight profile with competent lips (Figure 1). On smiling, both posed and unposed , clearly indicated that the patient had excessive show of gingiva and the patient was very conscience of the same (Figure 2a, 2b )

119. Close-up photographs were taken with a metallic scale placed vertically, such that it coincidedwith the facial midline during posed and unposed smile. 4-5mm of gingival exposure was seen in the incisor region during posed smile (Figure 3a). With spontaneous, unposed smile, as detected by the expression of the eyes, patient showed a gingival display of 8-10mm (Figure 3b). On further examination, hyperactive upper lip elevator muscles were seen. The photographs clearly showed the presence of excessive gingival display with hyperactive upper lip elevator muscles. As the patient was unwilling to undergo Orthodontic or Orthognathic surgery, the treatment objective was to treat the gummy smile with Botulinum toxin type- A. Treatment Objectives

120. Treatment Progress The procedure was performed by a Dermatologist who was also a Botox certified physician. Botulinum toxin type-A was diluted according to manufacturer’s recommendations to provide 2.5 units per 0.1ml by adding 4.0 ml normal saline solution to 100 units of vacuum-dried Clostridium botulinum toxin type-A. Under sterile conditions, 2.5 units were then injected at 2 sites per side in both overlapping points of the right and left levator labii superioris alaeque nasi , levator labii superioris and zygomaticus minor and levator labii superioris muscle sites (Figure 4 ). The sites for injection were determined to ensure accurate locations of the muscle. This was carried out by asking the patient to smile and simultaneously palpate the muscles on contraction. No local anaesthesia was administered and no electromyographic guidance was used.

121. Facial photographs were recorded after two week post treatment using the same equipment. Extreme effort was placed on obtaining standardised , unposed , spontaneous smiles (Figure 5a, 5b, 5c). Remarkable improvement in the lip profile was seen and gummy smile reduced to a normal range.