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Uncovering Smiles by Dr. Jeremy Manuele

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Categories: Orthodontics;
Uncovering Smiles 

Simple “CYCLOPS” TAD mechanics to increase incisal display

by Dr. Jeremy Manuele

Introduction
It all started with a simple conversation at my office. My brother had come into town and wanted to check out my “workshop.” As he walked around, taking in the photos adorning the walls, he paused and asked me, “Why can’t you see my teeth when I smile?”

At first, I gave him the standard explanations—maxillary vertical deficiency, teeth that never fully erupted into the smile arc and the possibility of jaw surgery to correct it. But as I spoke, I realized he wasn’t just making small talk—he was genuinely curious. Why didn’t his teeth show despite being straight? He had worn braces as a teenager, yet his smile didn’t look like the ones on my walls. And more importantly, could anything besides jaw surgery change this?

My brother has a background in engineering, and true to form, the more I explained, the more questions he had. Together, we began brainstorming ways to extrude his teeth and enhance his smile. As orthodontists, we know that bone and gums follow the teeth during extrusion. So why don’t we explore this option more often? His curiosity drove us to a rudimentary solution: a temporary mock-up (Fig. 1). I used color-matching composite and a curing light to bond his teeth, adding enough length for a glimpse of what might be possible. It required more length than I expected (Fig. 2).
Fig. 1
Manuele Cyclops TADs
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Fig. 2
Manuele Cyclops TADs
Manuele Cyclops TADs
 

When I handed him the mirror, I saw a shift in his demeanor. He studied the temporary restorations with intense focus. I’ve never known my brother to be particularly interested in smiles—he’s more of a practical, “if it ain’t broke, don’t fix it” type. But in that moment, I could tell that seeing his smile in a new light had a profound effect on him.

At that moment, I made a commitment: I needed to find a way to help people like my brother achieve the smile they deserve. Orthodontists are uniquely positioned to address these cases without resorting to invasive jaw surgery or full-mouth rehabilitation.

I had always been comfortable with TADs, so I began considering how to leverage them to accomplish this goal. I had used them to treat gummy smiles through intrusion, but I needed a way to use them for extrusion.

As a user of the Dentaurum TAD system, I pulled out my trusty Tomas auxiliary kit, and the answer was staring me in the face. The cross-tube component caught my eye, and everything clicked (Fig. 3). The mechanics are surprisingly straightforward, but allow me to walk you through a case to hopefully gain a deeper understanding.
Fig. 3
Manuele Cyclops TADs


Case overview
This patient presented as a 26-year-old female whose chief concern was crowding (Fig. 4). As you can see in the pretreatment smile and lateral cephalometric images, she only showed a few millimeters of teeth when smiling. Additionally, there was a noticeable maxillary cant, deep bite and flat occlusal plane. We decided to start by using reverse curve of Spee (RCOS) wires in both the upper and lower arches, both angling downward. I prefer this orientation, especially in deep bite cases with limited smile show.

 Fig. 4
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
Manuele Cyclops TADs
 


Quick tip: Academically, you might think the RCOS wire on the upper arch would be counterproductive to deep bite correction, but in practice, extruding the maxillary posterior teeth has a greater impact on correcting the deep bite than extruding the incisors. So, you get a double benefit: more smile show and deep bite correction at the same time.

We worked up to a 20-by-20 stainless steel wire, at which point we performed a maxillary frenectomy, then placed a TAD between the roots of the central incisors. Next, I custom-bent an 18-by-25 stainless steel wire segment, placed it into the TAD head slot, covered it with flowable composite and added a NiTi open coil spring (OCS), approximately 2 mm active. The cross tube was then placed on the main wire and fed through the auxiliary wire, compressing the OCS and leaving a few millimeters of wire extending toward the incisal to allow the teeth to slide along as they extruded. To ensure patient comfort, I covered the exposed wire with flowable composite (Fig. 5).

 Fig. 5
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 

Quick tip: Before you place the upper 20-by-20 stainless steel wire, add some curve of Spee with the anterior portion pointing up. This may seem counterintuitive, but the intrusive forces of the wire on the incisors won’t overcome the pushing forces of the TAD mechanics. As a result, as you extrude, the canines and premolars will follow along nicely and maintain arch level.

It is also important to note that when you bend your 18-by-25 auxiliary wire, bend it in such a way that the wire moves facially as it moves away from the TAD. This will help ensure you don’t retrocline the incisors as you extrude them.

After two months of extrusion, you can see that the cross tube has slid down to where the flowable composite was initially placed (Fig. 6). At that point, I gently removed the composite by squeezing lightly with Weingart pliers.

 Fig. 6
Manuele Cyclops TADs
Manuele Cyclops TADs
 


After four months of extrusion, the OCS was no longer active, so we added a crimp stop—crimped just enough for retention while still allowing it to slide on the wire (Fig. 7).
Fig. 7
Manuele Cyclops TADs
Manuele Cyclops TADs
 


After six months of extrusion, we still wanted a little more smile show, so we removed the main wire and adjusted the orientation of the cross tube so that the longer arm was vertical. Then we replaced the OCS with a longer, more active one (Fig. 8).

 Fig. 8
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 


After we were satisfied with the extrusion we had achieved, we finished up with a few archwire detailing visits before removing her braces (Fig. 9). Her total time in braces was 19 months.

 Fig. 9
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele Cyclops TADs
Manuele Cyclops TADs
 


The before-and-after smiling photos, along with the pretreatment and post-treatment 3D sagittal superimposition, best illustrate the amount of extrusion achieved (Fig. 10).

 Fig. 10
Manuele Cyclops TADs
Manuele Cyclops TADs
 
Manuele-Cyclops-TADs-Fig10-Video



This technique proves equally effective for teenagers, offering a promising alternative for younger patients as well (Fig. 11). While preparing this article, I discovered that others have published similar techniques with great results.1
Fig. 11
Manuele Cyclops TADs
Manuele Cyclops TADs
 
Manuele Cyclops TADs
 
Manuele-Cyclops-TADs-Fig11-Video



Conclusion
There’s nothing more fulfilling than giving someone a smile they love. As orthodontists, we have the privilege of shaping not only a patient’s teeth but also their confidence.

My brother, though not ready for treatment yet, knows that when he is, I’ll be there to help him achieve the smile he saw in our mock-up session. This journey has not only been about professional innovation but also about personal connection, reinforcing the profound impact of orthodontics on individual lives.

The “CYCLOPS” technique represents a significant advancement in orthodontics, offering a less invasive, more tailored approach to enhancing smile aesthetics. It’s a testament to the power of curiosity, collaboration and the relentless pursuit of improved solutions in our field. For fellow practitioners, I hope this technique not only excites but also inspires further exploration and sharing of knowledge, fostering a community dedicated to improving lives one smile at a time.

References
1. Liaw, J. J. L., et al. “Total Arch Extrusion with Skeletal Anchorage to Improve Inadequate Maxillary Incisor Display in a Case of Vertical Maxillary Deficiency.” The Angle Orthodontist, vol. 94, no. 2, 2024, pp. 247–257, https://doi.org/10.2319/070323-462.1.
Author Bio
Dr. Jeremy Manuele Dr. Jeremy Manuele is an orthodontist and course director of the MARPE 360 online CE course. He holds a DMD from the University of Nevada, Las Vegas, and a certificate in orthodontics from LSU Health Science Center and is board-certified. With 21.5 years of service in the Army National Guard, including a deployment to Ramadi, Iraq, Manuele brings a unique perspective to his work. As a partner orthodontist at Hamilton & Manuele Orthodontics, he leads in advanced techniques like in-office aligner fabrication, digital indirect bonding, laser welding and MARPE/TAD procedures. He also serves as a part-time faculty member at UNLV School of Dental Medicine, shaping the future of orthodontics.

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