TAD Max by Dr. Wassim Bouzid

Categories: Orthodontics;
TAD Max 

Treating a gummy smile with miniscrews and passive self-ligation

by Dr. Wassim Bouzid


An individual’s smile is the second facial feature that people tend to evaluate when assessing attractiveness. Orthodontists strive to improve smile aesthetics, enabling patients to reach social and psychological well-being while improving their oral health.

When the soft-tissue paradigm in orthodontics was introduced, aesthetically aware orthodontists shifted their vision from pure dental and skeletal orthodontic diagnostic and treatment planning to profile-based diagnostic and treatment planning. Treatment goals were directed to improve, or at least maintain, the profile’s aesthetic appearance.

More recently, facially driven approaches considered harmonizing smile aesthetics with the facial attributes of the patient, seeking aesthetic tooth positions and optimized white/pink tissue contours within the smile frame and face.

Today’s aesthetically focused orthodontists actively incorporate factors into treatment planning that are described by our cosmetic dental colleagues as “smile design”: facial flow, lip frame and contour, smile arc, incisor dominance, enamel display, tooth proportionality, buccal corridors, axial inclination of both incisors and buccal segments, dental f low, tooth color, and gingival contour and quality.

This article will demonstrate how aesthetic parameters can be met even in patients who have significant discrepancies, given sufficient planning and patient cooperation, without sacrificing excellence in functional occlusal goals. In this example, a severe gummy smile was treated with a combination of a passive self-ligating system and extraradicular miniscrews (TADs).

The treatment techniques of “active early” case management protocols were taught to me by my mentors, Drs. Tom Pitts and Duncan Brown. I am grateful to them for guiding me in how to stretch the limits of orthodontics to achieve exceptional aesthetic results. In a world where facial aesthetics is of major importance and patients are more demanding of exceptional aesthetics—fuller profiles and lips, broader white smiles with increased enamel display and upright upper incisors—these techniques are very useful.

In the final analysis, meeting or exceeding patients’ aesthetic expectations goes a long way in establishing their satisfaction during the treatment experience, and reestablishing the relevance of orthodontic treatment in aesthetics.

Fig. 1

Clinical case

This 28-year-old patient (Fig. 1) sought orthodontic treatment to resolve her severe gummy smile. Her chief complaint was focused on the excessive visibility of the gingiva when smiling.

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

The treatment plan was to use the combination of passive self-ligating brackets and extraradicular temporary anchorage devices to en masse affect the maxillary dentition. Refinement of white and pink tissues would be undertaken with coronoplasty and laser recontouring of the pink tissues.

We placed upper and lower Pitts 21 fixed appliances, with the smile arch protection (SAP) bracket positioning approach. Posterior bite turbos were bonded on the upper first molars and 0.014-inch thermal-activated NiTi Pitts Broad upper and lower were placed as initial wires. On the second appointment, upper and lower arch wires were changed to 0.018-by-0.018-inch Ultra Soft Pitts Broad to help widening the arches. Consistent with the VEO, interproximal reduction was performed on engagement of the square wire. A detorquing chain was inserted on the lower arch to help the uprighting control of the lower incisors.

After eight months of treatment, 0.019-by-0.019-inch stainless steel Pitts Broad wires were placed on both upper and lower arches. Six stainless steel Bioray miniscrews were inserted on the upper arch and impaction of the maxillary dentition initiated (Fig. 5):

  • 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.
Fig. 5

After 14 months of treatment, a full set of intra- and extraoral photos was taken to objectively assess case progress (Fig. 6). A noticeable positive change is observed on the patient’s posed smile, with a reduction on the gingival exposure when smiling.

Fig. 6

For the purpose of comparison and evaluation of the treatment progress, I have adopted a nonconventional comparison technique introduced to me by Dr. Ahmed Zribi from Tunisia. The method consists of having the same side hemiface of the pre- and mid-treatment smiling photographs calibrated together according to the eyes and the nose, comparing both sides of the face and the amount of the effective intrusion that occurred during the impaction process (Fig. 7).

Fig. 7

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. 12

Using the VEO template, the need for any additional white or pink aesthetic refinements was assessed. The analysis revealed the necessity of gingival recontouring to enhance the pink aesthetics, create a more natural smile and dramatically change the overall facial aesthetics. Consequently, a gingival recountouring procedure was performed using an ultrapulse diode laser (Spectralase 980).

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. 15

All of these parameters contributed to a transformational outcome for her overall facial aesthetics. Fig. 16 shows the pretreatment versus post-treatment panorex and headfilm; Fig. 17 and 18, respectively, illustrate the treatment progress from zero to 30 months.

Fig. 16: Pre- and post-treatment panos and cephs.
Fig. 17

Fig. 18


Gummy smile treatment is considered one of the most, if not the most, challenging and difficult cases in the orthodontic field, with many orthodontists considering surgery as the only option for this kind of discrepancy. This clinical case report demonstrates an efficient and pragmatic way to treat gummy smile with confidence, using the combination of Pitts 21 bracket system, Pitts protocols and extraradicular TADs to create an extraordinary transformational result for this patient.

I believe the goal for aesthetic orthodontists reaches beyond giving the patient what they want, to results that they never thought it was possible for them to have. The dramatic contrast in Fig. 18 is a perfect example of what we must consider for our patients.

The concepts of aesthetic-first, efficient “active early” treatment protocols, advanced technological appliance systems and a laser focus on microaesthetics will enable clinicians to reach the next level in orthodontics. This will secure a relevant role for orthodontists in the transdiscplinary world of aesthetic providers.
Author Bio
Wassim Bouzid 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.
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