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Occlusal Plane Control by Dr. Wassim Bouzid

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Categories: Orthodontics;
Occlusal Plane Control 

A critical consideration in the aesthetic resolution of a high-angle Class II patient with a “gummy smile”

by Dr. Wassim Bouzid

Introduction
Aesthetic considerations are often the primary motivation for patients seeking orthodontic treatment. However, many patients are frequently unaware of the underlying skeletal discrepancies that contribute to their concerns. Appreciation and then management of skeletal attributes that positively impact aesthetics open many nonsurgical options for these patients. This article will document the treatment of a 28-year-old female patient who presented with protruded upper incisors as her chief complaint. Meticulous evaluation of her presenting aesthetic, dental and skeletal attributes revealed that her situation was far more complex, requiring more than simply moving teeth.


Diagnosis
A comprehensive examination and record analysis revealed significant skeletal discrepancies, including a severely retrognathic mandible and a tendency toward a gummy smile, consistent with a Class II high-angle malocclusion (Figs. 1–3).

This patient displays many of the reported features of Class II malocclusions, including a constricted maxilla and mandible, as well as notable crowding in the upper arch and slight crowding in the lower arch. The soft tissue profile was aesthetically displeasing, with a deep labiomental fold, an everted lower lip and strained lip competence.

In this facial pattern, the mandible is small and rotated clockwise, resulting in the upper and lower occlusal plane being steep and a significant discrepancy between points A and B. This requires a treatment strategy directed toward adjustment of the occlusal planes in addition to a dental correction.

Using the Pitts aesthetic templates (Figs. 4 and 5), we noted a favorable smile arc typical of Class II patients, indicating a steep occlusal plane directly influenced the smile dynamics. The patient displayed excessive gingival exposure upon smiling, a constricted dental arch, proclined upper incisors and a need for enhancement of her micro-aesthetic attributes.
Occlusal Plane Control
Fig. 1
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Fig.2
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Fig.3
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Fig.4
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Fig.5


Treatment strategy evolution
At the outset, we had hoped to avoid full-arch impaction, as the patient had concealed the extent of her “overexposure” in posed smile photographs. During conservative treatment it became obvious that full-arch impaction would be required, so it was undertaken.

A treatment strategy evolved to simultaneously control the vertical position and rotation of the upper and lower occlusal planes, improve the dental relationships and optimize “white and pink” aesthetic parameters (Figs. 6–8). TAD-assisted impaction of the maxilla was undertaken using four mini-screws instead of the conventional six—a rationale that is discussed later—intruding the entire maxilla to reduce the vertical dimension and permit auto-rotation of the mandible to improve the skeletal discrepancy.

Desired dental movements were attained with elastic forces from the IZC TADs and expansion of the dental arches. Slenderizing helped relieve crowding while improving the aesthetic proportions of the anterior teeth. Pink tissue revision with a diode laser was planned.
Occlusal Plane Control
Fig.6
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Fig.7
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Fig.8


Treatment records
The patient was scheduled for placement of a fixed passive self-ligating appliance (OC Orthodontics, Pitts21) from second molar to second molar in both arches. Initial archwires included upper and lower 0.014 Pitts broad thermal-activated NiTi wires. After achieving alignment, a 0.018 Pitts broad thermal activated NiTi wire was placed, followed by a 0.018-by-0.018 Pitts broad UltraSoft thermal activated NiTi wire. IZC TADs (BioRay 2-by-12 mm) were placed to control the posterior occlusal plane.

During the initial phase of treatment, significant flaring of the lower incisors developed. A decision was made to utilize Class III elastics from the upper second premolars to the lower canines (3/16”, 3.5 oz), alongside a reverse rainbow elastic for nighttime wear (5/16”, 2.5 oz). Interproximal stripping and torquing chains were employed to control lower proclination and upright the lower incisors (Fig. 9). We have found that it is more efficient to run long Class III elastics from the IZC TADs (1/4”, 6 mm, 3.5 oz) to the lower canines, controlling the lower occlusal plane and promoting a counterclockwise mandibular rotation, and we now adopt this strategy routinely.

Twelve months into treatment, maxillary intrusion commenced with the insertion of a 0.019-by-0.019 stainless steel archwire. The strategy was to use four mini-screws (BioRay A1), two 2-by-8 mm screws positioned between the upper centrals and upper laterals, and two 2-by-12 mm IZC screws. Power chains were used to ligate the anterior mini-screws to the archwire to induce full intrusion, while two additional power chains connected the infrazygomatic screws to the upper canines for slight distalization of the maxillary dentition (Fig. 10).
Occlusal Plane Control
Fig.9
Occlusal Plane Control
Fig.10


Rationale for mini-screw strategy
Full maxillary impaction commonly requires using six mini-screws (two anterior, two IZC and two palatal). In this case, four TADs were sufficient, as anterior screws provided intrusive anterior forces, while the IZC screws contributed to a moment that provided both a pull-back force and intrusive posterior and extrusive anterior moments. This protocol enabled a controlled rotation of the upper occlusal plane counterclockwise while it was intruded. The intrusive forces originating from the anterior power chains effectively countered any extrusive forces, resulting in full-arch intrusion without the need for palatal screws (Fig. 9).

Twenty months into treatment, maxillary intrusion was ceased based on the assessment of the incisor display ratio (Figs. 11, 13, 14). Digital smile design templates with a 72% incisor-to-lip ratio guided this decision, ensuring optimal aesthetic results (Fig. 12). The final smile projection analysis demonstrated that only 1 mm of gingiva would remain visible after the planned laser gingivectomy.

Figure 15 compares the initial and post-treatment lateral cephalograms, demonstrating skeletal and dental changes. The upper occlusal plane rotated counterclockwise and intruded, while the lower occlusal plane rotated counterclockwise, improving the chin projection. Figures 16 and 17 demonstrate the impact of pink tissue revision with a diode laser, three weeks after the removal of fixed appliances. Bleaching of the teeth post treatment ensured a beautiful smile presentation.
Occlusal Plane Control
Fig. 11
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Fig. 12
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Fig. 13
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Fig. 14
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Fig.15
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Fig. 16
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Fig.17


Clinical and aesthetic outcomes (26 months)
Intraoral results. Figures 18–20 illustrate the final treatment result. The patient achieved Class I molar and canine relationships bilaterally. Proper overjet and overbite were restored, and the midline alignment was excellent.

Extraoral results. Figure 21 compares the patient’s smiling photographs before and after treatment. Significant improvements were noted in the smile arc, incisor exposure and overall facial aesthetics. The lateral profile photographs (Figs. 22 and 23) clearly show an enhancement in the soft tissue profile, a counterclockwise rotation of the occlusal plane and optimized smile projection.

Mini aesthetic results. Figure 23 highlights the noticeable enhancement in mini aesthetic parameters, including improved smile arc, incisor positioning and symmetry. Micro-aesthetic adjustments and gingival contouring provided beautiful white and pink aesthetic results.

Smile presentation photographs in frontal, oblique and profile views (Fig. 24) further demonstrate the macro, mini and micro-aesthetic improvements achieved during treatment.
Occlusal Plane Control
Fig.18
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Fig.19
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Fig.20
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Fig.21
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Fig. 22
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Fig.23
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Fig. 24
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Fig. 25



Long-term aftercare and stability
One of the things I particularly enjoy about orthodontics is when our treatment efforts contribute in some manner to life-changing alterations for our patients. One year post-treatment, the patient returned for a follow-up consultation. The patient reported improved self-confidence, which motivated her to adopt a healthier lifestyle, leading to a 20 kg weight loss. The post-treatment frontal smiling photograph reflects a transformation well beyond dental changes. The orthodontic result remains stable, with no relapse in occlusal relationships or aesthetics, as the patient is highly motivated to retain this result as a significant aspect of her new persona (Fig. 25).


Conclusion
This case highlights the importance of occlusal plane control and interdisciplinary planning in the treatment of Class II high-angle malocclusions with excessive gingival display. Combining orthodontic mechanics with digital smile design and micro-aesthetic refinements helps us to achieve a transformation in dental and facial aesthetics.
References
1. Fushima, K. “Significance of the Posterior Occlusal Plane in Class II Div I Malocclusions.” European Journal of Orthodontics, vol. 18, 1996, pp. 27-40.
Author Bio
Dr. Wassim Bouzid Dr. Wassim Bouzid received his Doctor 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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