TAD Max by Dr. Wassim Bouzid

Treating a gummy smile with miniscrews and passive self-ligation

by Dr. Wassim Bouzid

In conventional thinking, this skeletal discrepancy would be treated with a maxillary superior repositioning surgery (LeFort 1 osteotomy) to reduce the associated vertical maxillary excess.

Lately, Botox injections, lip repositioning surgery and crown lengthening have gained in popularity among aesthetic providers, and these are good options for some patients in getting pleasant results.

These techniques have understood limitations, considering the need for reinjection every six months (Botox), high risk of relapse (lip repositioning) and a limited indication in patients with short clinical crowns (crown lengthening).

The clinical examination of this patient revealed that she displayed a mild Class 2 dental malocclusion with a deep overbite. On animated smile, the patient displayed 9 millimeters of gingival exposure, retroclined upper incisors and aesthetically narrow upper and lower arches. Four wisdom teeth were present, so their extraction was selected as a preferred option (Fig. 2).


Fig. 2

Visual esthetic outcome (VEO) was performed during the initial exam to show the patient the amount of intrusion that would be needed to get a pleasant aesthetic result (Figs. 3 and 4).

Fig. 3

Fig. 4

• Two 12mm miniscrews were inserted on the infrazygomatic crest; care was taken to put the screws as high as possible to give the power chain a certain length to allow an intrusive force to take place.
• Two 12mm miniscrews were inserted on the palate between upper 6 and upper 7, and four lingual buttons were bonded to the palatal surface of both molars to engage a power chain to prevent the side effect of a posterior buccal segment flaring on intrusion.
• Two 8mm miniscrews were inserted between the upper centrals and laterals to not only help the intrusion but also to get some positive inclination during the impaction, because the upper front teeth were lingually inclined initially.

After 20 months of treatment, when anterior intrusion had been attained and the amount of gingiva exposure was very minimal, two metal ligatures were secured to the arch wire anteriorly to impede any extrusion (Fig. 8).


Fig. 8

Because smile analysis revealed that the smile arch had been flattened during the impaction process, it was decided to continue intruding the upper posterior segment, to tip the occlusal plane “clockwise” and enhance the smile arc. The approach was continued for another eight months, producing a significant positive change on the smile arc (Fig. 9).


Fig. 9

A pleasant change on the inclination of the upper front teeth was noticeable at this point, mainly due to the intrusive force that had been applied to the front teeth, which resulted on upper incisors uprighting. Finishing bends were introduced at this stage on the 0.019-by-0.019-inch stainless steel Pitts Broad in addition to some tooth recontouring and reshaping to refine the overall microaesthetic aspect (Fig. 10).


Fig. 10

After 30 months of treatment, the orthodontic appliance was removed and a set of intraoral and extraoral photos was taken to evaluate the overall change (Figs. 11 and 12).

Fig.11

Fig. 12

The benefits of obsessive detailing on the microaesthetic principles of gingival embrasures and the zenith points makes a huge difference; an intraoral photo (Fig. 13) was taken just after the laser remodeling procedure. Final photographs were taken 30 days after the laser procedure.


Fig. 13

It took 30 months to reach the final results (Fig. 14). Occlusally, a solid Class 1 canine and molar relationship have been achieved, a “socked-in” occlusion has been attained, and both upper and lower midlines are coincident with the facial midline. Patient photos reveal a broader smile, upright upper incisors, coincident smile arc and attractive exposure of the upper incisors and the gingiva. There is improvement of the lingual inclination of the upper incisors, and the patient displays a better inclination of the front teeth along with a profile enhancement (Fig. 15).

Fig.14

Fig. 15

Fig. 16: Pre- and post-treatment panos and cephs.

Fig. 17

Dr. Wassim Bouzid received his doctorate of dental medicine from Algeria’s Constantine University in 2007, then earned his master’s degree in orthodontics and dentofacial orthopedics from Wuhan University in China. He owns OrthoVision, a practice in Constantine, and is board-certified in Algeria. A member of the second Pitts Master Program and an international speaker in orthodontics, Bouzid has lectured in more than 15 countries and published several articles. He also is a professional photographer and is certified in digital smile design.