Townie Treatment Case: Gummy Smile Treatment With Aligners by Dr. Trevor Nichols

by Dr. Trevor Nichols

• Hyperactive upper lip muscles. These may cause the upper lip to lift higher than usual during a smile, exposing more gum tissue.
• Shorter teeth. People with genetically shorter teeth may be more prone to displaying excess gum tissue when smiling.

• Maxillary vertical excess. If there is an excessive vertical development of the maxilla, it can result in a gummy smile as more of the gums become visible when smiling.

• Lip length and mobility. A shorter upper lip or increased mobility may contribute to a gummy smile.
• Gingival tissue thickness. Thicker gingival tissue can contribute to a gummy smile by covering more of the teeth.

• Imbalance in facial musculature.
• Abormal craniofacial growth patterns.

• Tooth size and shape. Disproportionately small or short teeth may contribute to a gummy smile.
• Tooth eruption patterns. Identify any abnormalities that may contribute to the gummy appearance.

• Lip mobility and length. Examine the upper lip as the patient smiles. A short upper lip or excessive mobility may contribute to the exposure of excessive gum tissue.
• Gingival tissue thickness. Thicker tissue can contribute to a gummy smile.
• Smile line. Assess the relationship between the upper lip and the upper teeth to determine the extent of gum exposure. This should be evaluated both as the patient smiles and when the incisal display is at rest.

• Maxillary vertical excess. An excessive vertical development of the maxilla can contribute to a gummy smile.
• Facial growth patterns. Evaluate the overall growth patterns of the face, including the relationship between the upper and lower jaws.

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• Take excellent records.
• Determine if, and how much, intrusion is needed. (Anything 4 mm or more will require TADs.)
• Scan the patient.
• Depending upon where the intrusion is to take place, add a fixed wire to the area of intrusion. (This can be done chairside, or using a printed model.)
• Anterior intrusion: Fixed U3–3 lingual (Fig. 4).
• Posterior intrusion: Fixed U4–7 occlusal (Fig. 5).

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• Ensure intrusion is set up in the software.
• Add buttons to upper 3s for anterior intrusion, and upper 4s and 6s for posterior intrusion.
• Simulate bite closure.
• Add lower buttons for elastics (Fig. 6).
• Ensure instructions are given to maintain fixed retention.

Fig. 6

• Deliver fixed wires, attachments, aligners and TADs.
• Tie TADs with PC from the buttons to the TADs (Fig. 7).

Fig. 7

• Continue replacing the PC every four weeks.
• Evaluate torque and ensure the patient is wearing trays.

• Tie TADs to buttons with elastics thread or stainless steel ligature wire (Fig. 8).
• Instruct the patient to wear medium side elastics.

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• Remove all buttons, TADs and fixed wires. If needed, a final refinement can be done to settle the occlusion and detail.
• Most cases will require gingival contouring at the end of treatment.
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Dr. Trevor Nichols attended Arizona State University, where he completed a bachelor’s degree in science and fitness and graduated as valedictorian. He then attended the Arizona School of Dentistry and Oral Health for his doctoral training, where he served as class president. While there, he also completed a certificate in dental public health. After obtaining his DMD, Nichols completed his specialty training in orthodontics at ASDOH and earned a master’s degree while completing research on TMD. He has also received inaugural awards in clinical excellence and leadership. Nichols is involved in organized orthodontics and as a lecturer educates other orthodontists and residents in the creation of beautiful, healthy, life-lasting smiles.