Life Changing Results by Dr. Wassim Bouzid

Categories: Orthodontics;
Life Changing Results 

A comprehensive aesthetic assessment and an aesthetically focused treatment approach

by Dr. Wassim Bouzid

Orthodontists generally embrace research that supports an aesthetic smile as contributing positively to a patient’s selfconfidence and emotional well-being,1 directly affecting their quality of life. The assessment of the factors contributing to an aesthetic smile have extended considerably from the landmark works of Dr. David Sarver on the value of smile arc2; aesthetically driven orthodontists have become familiar with the many factors in addition to smile arc that contribute positively to smile aesthetics.3 The influence of Drs. Tom Pitts and Duncan Brown enabled me to view the orthodontist’s role in the creation of smile aesthetics more broadly and taught me to apply the concepts of “power to move, add and reduce” to fully optimize smile aesthetics.

My friend, teaching partner and colleague Dr. Ilies Tibaoui and I have developed a simple system for the assessment of the elements of smile aesthetics that are directly under the influence of the orthodontist to guide our clinical actions. This assessment includes orthodontic tooth movement and microaesthetic manipulation of the white and pink tissues to attain “Wow!”-worthy treatment results.

Much has been written on the importance of incisor display in smile aesthetics. However, there has not been much coverage of the clinical approach to treat a lack of upper incisor exposure, which can have a significant long-term aesthetic consequence when present in a young patient.

In the Pitts aesthetic discipline, bracket placement, use of immediate light short elastics (ILSE) and disarticulation are valuable tools to control tooth position for optimal aesthetics and rotate the cant of the upper occlusal plane (COP) to aesthetic benefit. Miniscrews can help support these mechanics.

The purpose of this article is to demonstrate the value of applying the concepts of smile arc (SA), vertical incisor position (VIP) and vertical incisor display (VID) to a patient displaying significant incisor underexposure. The case demonstrates an unconventional treatment approach to optimize the final smile, optimizing the aesthetic outcome while respecting the uniqueness of the patient’s facial presentation.

Clinical case
Initial consultation and treatment plan
Aisha, a 26-year-old patient, sought orthodontic treatment with a primary concern centered around the crowding of her upper arch, an ectopic canine and the presence of an open bite.

During the initial consultation, we prioritized addressing her chief complaint, but it was important to explain that our concerns extended beyond these discrepancies; a significant aesthetic challenge lay in the limited display of her upper incisors when she smiled.

We explained that resolving this situation would not only transform the aesthetics of her smile but also make her appearance more youthful. Incisor underexposure had prematurely aged her, causing her to appear more like a woman in her 40s than her actual age of 26.

Dentally, we observed a unilateral crossbite and a substantial midline discrepancy, further contributing to her orthodontic needs. Furthermore, the cephalogram (Fig. 1) revealed a proclination of the lower incisors. A significant infection in the lower right first molar, necessitated extraction (Fig. 2) before commencing orthodontic treatment.

During the aesthetic assessment (Fig. 3), any attribute deemed unpleasant was marked with a red cross, while those considered very unpleasant received two such marks. (Any pleasant attributes would have been marked with a green check mark.) This systematic approach allowed us to obtain an objective assessment of the patient’s aesthetic presentation, proving immensely valuable during our digital smile design process as it guided us precisely on tooth movement in harmony with her facial features.

After identifying the patient’s negative attributes, we proceeded to use digital smile design templates that demonstrated ideal positioning of the upper incisors during her smile, relative to the smile arc target. Based on the desired tooth movements in relation to the face and smile, orthodontic biomechanics were planned that would enable us to attain this desired position effectively (Fig. 4).

Aesthetically focused treatment
Fig. 1
Aesthetically focused treatment
Fig. 2
Aesthetically focused treatment
Fig. 3
Aesthetically focused treatment
Fig. 4

To achieve the ideal aesthetic position for the upper incisors, it would be necessary to orthodontically extrude them to a significant extent, with the open-bite gap being closed by downward movement of the upper incisors. The conventional approach for treating an anterior open bite with inadequate upper incisor exposure involves using anterior elastics and was not ideal because it would result in both upper and lower incisor extrusion. Mild extrusion of the lower incisors to refine the occlusion would be acceptable after ideal positioning of the upper incisors was attained. The decision was to insert two intraradicular miniscrews (8-by-1.5 mm, BioRay) distal to Teeth #32 and #42 to facilitate maximal extrusion of the upper incisors without any unwanted extrusion of the lower incisors.

Desired upper and lower incisor position was supported by SAP++ bracket position, and would be adjusted by repositioning the incisor brackets as required. Posterior bite turbos placed on the upper second molars and PT exercises supported the mechanics by preventing counterclockwise rotation of the upper occlusal plane. Squeezing exercises are part of the Pitts protocol, in which the patient clenches on the posterior bite turbos 60 times, six times a day to prevent extrusion of the posterior teeth. We also used tongue tamers on the lingual surface of the lower incisors to encourage proper tongue posture and facilitate effective bite closure.

Treatment was initiated with upper and lower 0.14-inch nickel-titanium Pitts Broad archwire. Rainbow 2.5- ounce, 5/16-inch elastics were worn from the two lower miniscrews to the upper incisors to promote extrusion of those teeth. Lingual buttons on the palatal surface of the right premolar allowed wear of a 3.5-ounce, 3/16-inch crossbite elastic.

Case progress
After four months (Fig. 5), we progressed to a 0.18-by-0.18-inch Pitts Broad Ultra soft NiTi archwire, performed some interproximal reduction (IPR) and applied a detorquing power chain. Additionally, the patient was asked to wear triangular elastics from the lower left miniscrew to the upper left canine and premolar to aid in bite closure and correct the midline shift.

After six months of treatment (Fig. 6), we conducted two additional interproximal reduction (IPR) procedures and continued use of the detorquing power chain. The patient was instructed to maintain the same elastic wear regimen as before. As we evaluated the treatment outcome progress, we could confidently state that the patient was exhibiting a satisfactory level of incisor exposure (Fig. 7), a transformation that noticeably enhanced her smile and overall appearance.

After analyzing the pre- and intratreatment extraoral photos, we decided to readjust our biomechanics to achieve further aesthetic gains based on digital smile design templates (Fig. 8). It became evident that our patient would benefit from increased exposure of the upper incisors, which necessitated further extrusion, prompting us to reposition the six upper anterior teeth in a more gingival direction (Fig. 9). This adjustment aimed to create an improved smile arc and enhance VIP/VID when smiling.

Additionally, a 2-by-12-mm extraradicular miniscrew (Bioray) was added to the buccal shelf area of the lower arch. A power chain was placed from the miniscrew to the lower right canine to facilitate midline correction. It was crucial to remove the two lower intraradicular miniscrews used previously for extruding the upper front teeth before commencing midline correction with the buccal shelf screw. This precaution was necessary to prevent interference between the roots of the lower incisors and the two miniscrews, which could impede the correction process.

After 12 months of treatment progress (Fig. 10), we advanced to 0.19-by-0.19-inch stainless steel Pitts Broad wires in both the upper and lower arches. These wires allow finishing bends to refine aesthetics and occlusion. Additionally, we successfully aligned the upper and lower midlines to coincide. To further enhance the microaesthetics of the teeth, we performed some reshaping using flex disks, but minor adjustments were still required. These adjustments primarily involved addressing a slight canting of the upper arch and making minor occlusal refinements.
Aesthetically focused treatment
Fig. 5
Aesthetically focused treatment
Fig. 6
Aesthetically focused treatment
Fig. 7
Aesthetically focused treatment
Fig. 8
Aesthetically focused treatment
Fig. 9
Aesthetically focused treatment
Fig. 10

Case conclusion
After 14 months of treatment, small finishing bends for vertical tooth position and miniaesthetic white-tissue refinements were completed (Fig. 11). Many times, I am asked how the idealized tooth form is first visualized and then attained. As for our cosmetic dental colleagues, the establishment of aesthetic tooth shape determination is highly artistic. For women’s anterior teeth, we prefer width/height ratios in the 72%–75% range with long connectors, rounded incisal edges, and rounded and progressive incisal embrasures.

Final photographs and radiographs (Figs. 11 and 12) were taken two days after the removal of the brackets, marking an important milestone in the treatment process. From a dental standpoint, we have achieved a solid Class 1 canine and molar relationship, resulting in a harmonious occlusion. Also, the upper and lower midlines are aligned, enhancing the overall symmetry of the smile. The aesthetic evaluation of the patient’s photos highlighted notable improvements, including a broader smile, upright positioning of the upper incisors, a consonant smile arc and a pleasing display of the upper incisors, a particularly challenging aspect of this treatment. The combination of these factors has culminated in a remarkable transformation in the patient’s facial aesthetics (Figs. 13 and 14).
Aesthetically focused treatment
Fig. 11
Aesthetically focused treatment
Fig. 12
Aesthetically focused treatment
Fig. 13
Aesthetically focused treatment

Figs. 15–17 show the progression of treatment from its inception to the 14-month mark.

Aesthetically focused treatment
Fig. 15
Aesthetically focused treatment
Fig. 16
Aesthetically focused treatment
Fig. 17

Underexposure of the upper incisors when smiling is a highly unattractive and unaesthetic feature. We strongly believe that having misaligned or protruded teeth when smiling can still be deemed acceptable when compared to the complete absence of tooth display. In cases like these, conducting a comprehensive digital smile design analysis becomes crucial. It allows the clinician to determine the optimal amount of incisor extrusion and enables them to plan biomechanics accordingly.

A final word on biological availability, biological response, reasonable expectations and permanent retention: Each patient presents with different aesthetic needs and differing biological availability, and will exhibit different biological responses to treatment. Our role as responsible clinicians is to assess these before entering into treatment, continually monitor them during treatment and adjust our approach accordingly. Very thorough assessment and continuous communication with the patient through treatment avoids potential disappointment when a desired result is not reasonable or beyond the patient’s availability to attain.

We advocate permanent retention of orthodontic results. In this case, upper and lower fixed retention (3–3 upper and lower) and upper and lower Essix-style retainers were provided. Tongue tamers are maintained during retention for at least a year. Clear attachments applied to upper and lower cuspids can be used for light vertical elastics if required. Squeeze exercises are continued during retention. We have found results to be very stable using this approach.

Author’s note: I am most grateful to my teachers, mentors, my team at OrthoVision, my teaching partner, Dr. Ilies Tibaoui, and to you readers for your roles in helping Aisha get the smile she had only dreamed of. Her spirit was always beautiful, but was hidden by self-doubt in the same way that her upper incisors were underexposed. Through the miracle of orthodontics, she is now sharing that joy with the rest of the world. A life-changing experience!

1. Rios, K. “Laypeople’s Perceptions of Smile Esthetics.” J Oral Research.
2. Sarver, D. “The Importance of Incisor Positioning in the Esthetic Smile: The Smile Arc.” Am J Orthodox Dentofacial Orthop 2001; 120:98–111.
3. Khan, M. “Analysis of Different Characteristics of a Smile.” BDJOpen 2020; 6:6.

Author Bio
Dr. 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 20 countries and published several articles. He also is a professional photographer and is certified in digital smile design.

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