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1. ETIOLOGY AND MANAGEMENT OF GUMMY SMILES

2. INTRODUCTION Smile is a pleased or amused expression of the face , formed by curling of the mouth upward. (Webster’s Dictionary) The evaluation of the smile has become an important part of our clinical assessment with a greater emphasis on dynamic assessment. Among the frontal features , Incompetency of lips, increased incisal show and gummy smile have become major concern for the patient.

3. The alignment ,position , the size of maxillary incisors and gingival line affect whether the smile is esthetic.

4. Definition : Gummy smile or high smile line or gingival smile line is a condition characterized by excessive exposure of maxillary gingiva during smile. Prevalence: 7% in young male 14% in young female Peck et all 1992 26% of sample of orthodontic patients display 2mm or more maxillary gingival during smile. At smile Over exposure seen in repose of lips Also known as high lip line or Full denture smile

5. ETIOLOGY Gingival display is a descriptive term rather than diagnosis which would mandate the initiation of a specific therapy

6. CLINICAL EVALUATION Facial symmetry and proportion of both frontal and lateral view. Facial balance – Its an assessment of vertical jaw relationships Three ratios. Evaluation of lip posture and incisor prominence. Lip prominence. Amount of incisor and gingival display Periodontal evaluation

7. FACIAL SYMMETRY AND PROPORTION OF BOTH FRONTAL AND LATERAL VIEW First ratio : Vertical Third Upper third - Trichion to Glabella. Middle third – Glabella to Subnasale. Lower third – Subnasale to Soft tissue Menton . Ratio should be 1:1:1 .

8. Second Ratio : Subnasale to upper lip stomion : upper lip stomion to soft tissue menton . Should be 1:2 . Third Ratio : Subnasale to vermillion cutaneous border of lower lip : vermillion cutaneous border of L/L to soft tissue menton. Ratio should be 1:1.

9. EVALUATION OF LIP POSTURE AND INCISOR PROMINENCE . Increased interlabial gap seen in Anatomic short upper lip. Vertical maxillary excess. Mandibular protrution with Openbite. Decreased interlabial gap seen in Vertical maxillary defficiency. Anatomic long upper lip. Mandibular retrution with Deepbite. Excessive separation of lips at rest called lip incompetence. The general guideline for all racial group is lip separation at rest should no more than 3-4 mm.

10. Lip prominence in the context of the relationship of the lips to the nose and chin can be assessed by drawing E-line(esthetic line) by from the nose to the chin . (nose tip to soft tissue pogonion) Lips should be slightly in front of this line.( Proffit ) Lower lip should be 0-2 mm away .( Reyneke )

11. Also called enjoyment smile or Duchenne smile(in research literature) In the Peck classification, a Stage II smile is a “ forced ” or strained posed smile resulting in maximal upper lip elevation. Thus, two types of posed smiles are possible: strained and unstrained.

12. 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. (31%) 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.(2%)

13. 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.

14. 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 .

15. Importance of incisal and gingival display Display of maxillary central incisor- young women – 3-4 mm , young men – 2 mm. As patients get older, the amount of incisor display at rest decreases with age, as does the amount of tooth display on smile. The clinician must be aware of this because the effect of diminishing incisor display results in hastening the aging process in terms of smile appearance. For this reason, in orthodontic treatment the choice to open a deep bite with upper incisor intrusion may correct the occlusion at the cost of making the patient look significantly older.

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

17. 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 Am 1998) 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.

18. 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.

19. 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

20. • According to Chang C et.al, (MOD0,2011) 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.

21. COMPONENTS OF BALANCED SMILE

22. 1. Lip line • The lip line is the amount of vertical tooth exposure in smiling i.e., 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 cervico-incisal 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)

23. The starting point of a smile is the lip line at rest, with an average maxillary incisor display of 1.91 mm 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 .

24. 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 female and 22 ± 2 mm for males (Reyneke J P)

25. The significance 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 commisure 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.

26. 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

27. 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. AdultOrthod.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)

28. 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.

29. 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. (SarverD.M. and Weissman S.M. Angle Orthod., 1991)

30. iv) Crown Height • The average vertical height of the maxillary central incisor is 10.6mm 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 wit gingival smile and a normal incisor display at rest.

31. v) Vertical Dental Height • A deep bite should be corrected by maxillary incisor intrusion in a patient with excessive incisor display at rest, but with posterior extrusion and/or lower incisor intrusion in a patient 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 res 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 I 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 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.

32. 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.

33. 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, downward when the corner of the mouth is lower than the central position .

34. 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.

35. 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 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

36. 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, 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

37. 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

38. According to contemporary aesthetic trends and the aging process, for adolescents and young adults, maxillary incisors should have, at rest, an exposure of about 4 mm beyond the most inferior point of the upper lip known as upper stomion . As explained earlier, an optimal functional overbite should be about 4 mm. Now, if we put together the last two concepts, the incisal edge of the lower incisors should be at the same level with the most inferior point of the upper lip. Therefore, any vertical change of the incisors will affect not only the function through changes of the anterior guidance, but also the aesthetics through the amount of tooth exposure. These anterior functional/aesthetic references explained by Ayala as the “upper stomion concept” will help the clinician to determine the best strategies to correct overbite/ overjet problems will have special importance for planning cases involving orthognathic surgery.

39. 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 apical 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%.

40. 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 Snaps, and saved as a JPEG file. • The smile image is then opened in a program called Smile Mesh, 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 )

41. • The diagnostic part of smile analysis begins with the creation of a problem list. • The first set of records analyzed is the extra oral 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 close up • Oblique smile close up

42. TREATMENT MODALITIES • 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 antero-posterior 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 & antero-posterior 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.

43. • 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.

44. Altered / delayed passive eruption • The goal of the crown lengthening procedure is to expose virtually all of the anatomic crown

45. 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

46. 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 Excessive Gingival Display the likely Differential Diagnosisis 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

47. • Partial thickness incision at mucogingival 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

48. 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 (B TX-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.

49. • 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.

50. Method Described by Polo (2005) 1.25U – right and left levator labii superioris (LLS) 1.25U – right and left levator labii superioris aleque nasii (LLSAN) 1.25U – at the overlap ares of LLS and zygomaticus minor ( ZMi )muscles 1.25U – origin of depressor septi nasi at the orbicularis oris (OO) Polo M. Botulinum toxin type A in the treatment of excessive gingival display. American journal of orthodontics and dentofacial orthopedics. 2005 Feb 1;127(2):214-8.

51. • BTX-A injections (2.5 units in both right and left overlapping points LLSAN and LLS , and Zygomatic Minor 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)

52. 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 Drug Induced Gingival Overgrowth, 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

53. Short Clinical crown MANAGEMENT

54. Short Clinical Crown When there is >3mm between crestal bone and gingival margin, only a gingivectomy is indicated. If the crestal bone and CEJ are approximating each other, a gingival flap surgery with osseous resection and apically repositioned flap is performed. Osseous resection is done till the crest is 2- 2.5mm from the CEJ

55. Loss of torque or palatally tipped maxillary incisors MANAGEMENT : If iatrogenic - incorporation of torque in the wire

56. Anterior dentoalveolar extrusion • Over eruption 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

57. 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.

58. Relative Intrusion • Can be accomplished with continuous arch wires 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 )

59. • 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 x 25 mil T MA 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 palatal root torque of the upper incisors is needed.

60. 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.

61. • The same effect can be produced by using the edgewise appliance , if the premolars and canines are bypassed with a 2 x 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 i.e. b/ n the 1 st molars and the incisors.

62. • Wire heavier than 16-mil steel should not be used, and a relatively soft 16 x 16 cobalt—chromium wire is recommended for utility arches to prevent heavy forces from being developed. • A more modern recommendation would be 16 x 22 ß-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 1 St 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

63. • 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.

64. BURSTONE'S SEGMENTAL ARCH: • Triple tube molar attachments are used • Heavy stainless steel anterior segment (0.021xO.025 ss) with T MA tip back springs (0.017xO.025) and • Passive segmented posterior stabilizing units (0.019xO.025) are placed.

65. K-SIR ARCH (Kalra Simultaneous Intrusion and Retraction 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" T MA 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° anti-rotation bends are placed to prevent molar rotations. • 0.019" x 0.025" T MA 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

66. 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.

67. Segmented Arch wires for Intrusion • This approach is recommended for maximum control of the anterior and posterior segments. • After preliminary alignment, a full-dimension rectangular arch wire 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 x 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 x 25. • In it, 17 x 25 steel wire with a 2½ -turn helix or 17 x 25 TMA wire works well. • If the auxiliary tube is 22 x 28, 19 x 25 TMA wire without a helix or preformed M- NiTi intrusion arch is acceptable, but the range of light force is lower.

68. • 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. An 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

69. (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.

70. • With careful attention to appropriate forces and moments with this approach, approximately four times as much incisor intrusion as molar extrusion in non-growing 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.

71. 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

72. 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 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.

73. • 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 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.

74. 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 an two molar, bypassing the canine and premolar is used made of 0.017xo.025 • Passive segmented posterior stabilizing unit (0.019xO.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.

75. • 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. • Mini implants 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

76. Vertical maxillary excess

77. High pull headgear • Restrains growth of the maxilla with extra oral 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 450gm) 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

78. 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 : Decreased gonial angle Redirection of condylar growth Increased posterior height.

79. 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

80. 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.

81. 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.

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