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Mini-implants for Gummy Smile Management: A Case Report
... Some authors agree on gummy smile treatment by orthodontic intrusion as Lahoti E., et al. [4] and Meriam Nasfi., et al. [5], while others agree with filler injections treatment which is thought to be an alternative method because it is effective and conservative and has high patient satisfaction as Ahmet Fatih Cengi., et al. [6] and Afnan F Al-Fouzan., et al. [7]. ...
This case report describes the treatment of a skeletal Class I malocclusion with a convex profile, involving a gummy smile with incompetent lips. The maxillary incisors were intruded and retracted with a nickel-titanium closed-coil spring anchored to a mini-implant, which were placed in the maxillary posterior and anterior areas. Mini-implants changed the left canine and molar relationship from Class II to Class I and resolved the gummy smile without extruding the maxillary molars or opening the mandible. The treatment was workable and simple, and the active period was 32 months. The patient received a satisfactory occlusion and an attractive smile.
This article describes the orthodontic treatment of a 19-year-old female patient with anterior crowding. There was a moderate arch length discrepancy in the lower dental arch, a significant deep overbite, and a "gummy smile." We inserted an orthodontic mini-implant as anchorage for the intrusion of the upper incisor segment, followed by alignment of the upper and lower dental arches with an edgewise appliance without tooth extraction. The overbite was corrected from +7.2 mm to +1.7 mm by upper incisor intrusion, and the gummy smile was improved. Good occlusion and facial esthetics were achieved, and these results have been maintained for two years after completion of the active treatment.
Introduction:
Dental intrusion has long been considered one of the most difficult movements to induce in orthodontics. Using conventional mechanics, the main difficulty lies in the need to ensure anchorage control, which is highly complicated to achieve, so as to avoid parasitic movements. In this framework, mini-screws have proven to offer a very effective means of anchorage, allowing greater control over intrusion of the anterior and posterior teeth and a simpler biomechanical movement opening up new therapeutic perspectives for the orthodontist.
Objective:
The aim of this study was to describe the clinical and biomechanical application of mini-screws for dental intrusion.
Not all patients with deep overbite should be treated with the same mechanics. Some patients require intrusion of the anterior teeth, while others require primarily extrusion. This article has discussed the principles of incisor and canine intrusion and has demonstrated the use of intrusion springs that are capable of intruding incisors with minimal side effects on the posterior teeth. Six principles must be considered in incisor or canine intrusion: (1) the use of optimal magnitudes of force and the delivery of this force constantly with low-load-deflection springs; (2) the use of a single point contact in the anterior region; (3) the careful selection of the point of force application with respect to the center of resistance of the teeth to be intruded; (4) selective intrusion based on anterior tooth geometry; (5) control over the reactive units by formation of a posterior anchorage unit; and (6) inhibition of eruption of the posterior teeth and avoidance of undesirable eruptive mechanics.
1.1. The primary treatment goal in orthodontics is to produce a well-balanced functional occlusion. However, a well-balanced smile is an additional, most important treatment objective.2.2. A proper evaluation of facial esthetics requires careful clinical inspection of the patient's smile before treatment commences. Full-face smile photographs are invaluable additional clinical tools in assessing the patient's smile before treatment and are recommended as standard photographic records in conjunction with the standard full-face and profile photographs.3.3. The ultimate position of the anterior teeth has a great influence on the relationship of the lips to each other and to the surrounding and underlying facial structures. A large improvement in facial balance when smiling has been demonstrated as a result of intrusion of maxillary incisors in conjunction with the proper amount of palatal root torque.4.4. The teeth should be moved with one mode of movement in a direct vector line, avoiding “round tripping” as much as possible. A selective torquing method which produces the necessary intrusion of maxillary incisors with the desired amount of palatal root torque within the edgewise mechanism is described.5.5. Improved facial balance during smiling is an essential treatment objective and adds an important dimension to successful orthodontic treatment. Treatment efforts of the orthodontist in this direction are highly valued by patients and parents alike.
A comparative study was performed to examine the nature of the gingival smile line (GSL), a specific dentolabial configuration characterized by the exposure of maxillary anterior gingiva during a full smile. Five soft-tissue, three dental and three skeletal variables were selected, measured and reported for a GSL sample (n = 27) and a reference sample (n = 88), both consisting of North American white orthodontic patients with a median age of 14.4 years. The results indicated that the capacity to project a gingival smile was related to: anterior vertical maxillary excess and the muscular ability to raise the upper lip significantly higher than average when smiling. Other variables significantly associated with GSL were greater overjet, greater interlabial gap at rest, and greater overbite. Factors that did not appear associated with the GSL phenomenon were upper-lip length, incisor clinical crown height, mandibular plane angle, and palatal plane angle. Clinical aspects of GSL were discussed.
The aim of the present study was to assess the changes in the periodontal tissue levels as an immediate result of the surgical crown lengthening procedure and over a 6-months healing period. 25 patients ranging between 20 to 81 years of age were included in the study. A total of 85 teeth (43 test and 42 control teeth not exposed to surgery) were evaluated over 6 months. After initial therapy, the indication for crown lengthening comprised need for increased retention and accessibility to deep subgingival preparation margins hampering impression taking. During surgery, the alveolar crest was reduced, thereby creating a distance of 3 mm to the future reconstruction margin. The results of this study demonstrated that the mean probable changes in the levels of the periodontal tissues from those defined after surgery were minimal, resulting in changes comparable to the shifts observed at control teeth not exposed to any surgical procedures. Frequency analysis of the number of sites with dislocation of the free gingival margin demonstrated that 12% of the sites with crown lengthening procedure showed 2-4 mm recession of the free gingival margin between 6 weeks and 6 months postoperatively. In esthetically critical, visible areas of the dentition, recessions must be closely observed in the healing period after surgical crown lengthening, when prosthetic reconstructions are planned on such teeth.
Elongated and spaced incisors are common problems in patients suffering from severe periodontal disease. Thirty patients characterized by marginal bone loss and deep overbite were treated by intrusion of incisors. Three different methods for intrusion were applied: (1) J hooks and extraoral high-pull headgear, (2) utility arches, (3) intrusion bent into a loop in a 0.17 x 0.25-inch wire, and (4) base arch as described by Burstone. The intrusion was evaluated from the displacement of the apex, incision, and the center of resistance of the most prominent or elongated central incisor. Change in the marginal bone level and the amount of root resorption were evaluated on standardized intraoral radiographs. The pockets were assessed by standardized probing and the clinical crown length was measured on study casts. The results showed that the true intrusion of the center of resistance varied from 0 to 3.5 mm and was most pronounced when intrusion was performed with a base arch. The clinical crown length was generally reduced by 0.5 to 1.0 mm. The marginal bone level approached the cementoenamel junction in all but six cases. All cases demonstrated root resorption varying from 1 to 3 mm. The total amount of alveolar support--that is, the calculated area of the alveolar wall--was unaltered or increased in 19 of the 30 cases. The dependency of the results on the oral hygiene, the force distribution, and the perioral function was evaluated in relation to the individual cases. It was obvious that intrusion was best performed when (1) forces were low (5 to 15 gm per tooth) with the line of action of the force passing through or close to the center of resistance, (2) the gingiva status was healthy, and (3) no interference with perioral function was present.
Myectomy and partial resection of the levator labii superioris promises a far better and direct approach to the problem of upper gum exposure during smiling. This procedure attempts to eliminate the cause of the deformity. The resected muscles are of the striated muscle group and are composed of single muscle fibers running the entire length of the trunk. Adequate resection of these muscles will thoroughly eliminate the regeneration of muscle, and thus a permanent correction is achieved. The resulting smile is very attractive and pleasing to both patient and surgeon.
As we complete the 20th and progress into the 21st century, orthodontists worldwide are experiencing a gradual but significant change in their practices. The number of adult patients has increased substantially. Although adults cooperate better than adolescents, they present a different set of challenges for the orthodontist. Adults may have worn or abraded teeth, uneven gingival margins, missing papillae, and periodontal bone loss, all of which can jeopardize the esthetic appearance of the teeth after bracket removal. This article will discuss the solutions for managing these challenging orthodontic-periodontic-restorative situations to produce a more ideal esthetic result.
As the public becomes increasingly concerned with looking younger and healthy, aesthetic considerations will become increasingly more relevant in dental treatment planning. As such, dentists must define the basic tenets of an aesthetic smile - extending that vision beyond simply "pretty teeth" to a concept whereby total dentofacial harmony is developed. Aesthetics is not simply a matter for restorative dentists - it uses restorative dentistry as one of the disciplines, but it is about beauty. The same rules that apply for a denture are therefore pertinent for crown and bridge and/or implants and must be applied in all aesthetic endeavors.
The problems related to anchorage for orthodontic tooth movements in patients with deficient dentition are discussed, and various solutions suggested in the literature, including "onplants," implants, and zygoma wires, are evaluated. A miniscrew is presented as alternative anchorage, and possible locations for placement are discussed, based on studies of bone quality in dry skulls. Application of the miniscrew as anchorage for various types of tooth movement is demonstrated. Miniscrews are easily placed and removed and can be loaded immediately following insertion. However, stability is limited after loading with torsion.
The primary characteristics of long face patients are gummy smile and/or anterior open bite. Consequently, correction of esthetic and functional problems are especially important for long face patients. Since orthodontic therapy alone is not sufficient to solve the problem, orthognathic surgical approach is indicated for these patients. In this report, orthognathic surgical therapy of a severe long face patient with similar findings was presented. Following clinical and cephalometric examination and preoperative orthodontic therapy, a Le Fort I osteotomy, a bilateral sagittal split osteotomy, and vertical and horizontal reduction genioplasties were performed. Alternative surgical therapies, complications, and the effects on the upper respiratory tract are also discussed.
In the analysis of the characteristics of a pleasant smile, a gummy smile has negative components, which most affect the esthetics of non-verbal communication. For this purpose a proposed classification based upon etiopathogenetic criteria as useful indications for a therapeutical approach is given. The nature of a high smile line can 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. A correct treatment plan must contemplate the possibility of an orthognatodontic, orthopedic and/or surgical therapeutic resolution considering the seriousness and complexity of the gums exposures (high smile line) in connection with the age of the subject.
A boy, aged 10.5 years, with a Class II molar relationship and a very deep overbite, complaining of a gummy smile and anterior crowding, was treated nonextraction with a mini-implant and Twin-block and edgewise fixed appliances. Severely extruded and retroclined maxillary incisors were intruded and proclined with a nickel-titanium closed-coil spring anchored to a mini-implant and segmented wires; this resolved the gummy smile and deep overbite efficiently without extruding the maxillary molars or opening the mandible. The mandibular incisors were proclined without direct orthodontic force during intrusion of the maxillary incisors; this helped the nonextraction treatment of mandibular incisor crowding. The Twin-block appliance with high-pull headgear promoted mandibular growth, restrained maxillary growth, and changed the canine and molar relationship from Class II to Class I. The patient's overbite and overjet were overtreated, and, 1 year postretention, the patient maintained a good overbite and overjet.
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