Journal of the World Federation of Orthodontists 2 (2013) e99ee106

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Journal of the World Federation of Orthodontists

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Case Report

Mini-implants for the management of a gummy smile

Carlos Alberto Estevanell Tavares a, Susiane Allgayer b, *, José Cícero Dinato c
a
Private Practice, and Associate Professor, Department of Orthodontics, Associação Brasileira de Odontologia, Seção Rio Grande do Sul, Porto Alegre, Brazil
b
Private Practice and Graduate and PhD Student, Department of Orthodontics, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
c
Private Practice, and Chairman and Professor of Dental Prosthesis, Associação Brasileira de Odontologia, Seção Rio Grande do Sul, Porto Alegre, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: This case report describes the treatment of a skeletal Class I malocclusion with a convex profile, involving
Received 9 February 2013 a gummy smile with incompetent lips. The maxillary incisors were intruded and retracted with a nickel-
Accepted 24 February 2013 titanium closed-coil spring anchored to a mini-implant, which were placed in the maxillary posterior
Available online 15 April 2013
and anterior areas. Mini-implants changed the left canine and molar relationship from Class II to Class I
and resolved the gummy smile without extruding the maxillary molars or opening the mandible. The
Keywords:
treatment was workable and simple, and the active period was 32 months. The patient received
Orthodontics, Corrective
a satisfactory occlusion and an attractive smile.
Tooth movement
Intrusions, Tooth
Ó 2013 World Federation of Orthodontists.
Esthetics, Dental
Analytical
Diagnostic and therapeutic techniques and
equipment category

1. Introduction 2. Diagnosis and etiology

Excessive gingival display during smiling, or gummy smile, is an
aesthetic problem for some patients [1e4]. It may result from
a variety of etiological factors [5,6]; therefore, proper diagnosis is
critical before beginning the treatment [5,6].
In adults, when the gummy smile is caused by overgrowth of
anterior vertical maxillary excess, the outcome may not always be
successful by conventional orthodontic therapy alone. In such
cases, surgical therapy, such as Le Fort impaction or maxillary
gingivectomies, are often indicated to achieve a good smile
[1,3,7e9]. However, if patients are unwilling to undergo surgical
treatment, an alternative method must be considered to treat the
gummy smile.
The traditional therapies, such as high-pull headgear [10,11],
may not work properly in adults. Some investigators have shown
successful intrusion of teeth with mini-implants as anchorage
[4,10e19]. Lin et al. [6] demonstrated successful treatment of
gummy smile patients using that skeletal anchorage. The present
clinical case describes the treatment of an adult patient with
gummy smile using miniscrew anchorage [4].
* Corresponding author: Clínica Tavares Ortodontia e Odontopediatria, Rua Fur-
riel Luiz de Vargas, 250/1404, CEP 90470-130, Porto Alegre RS, Brazil.
E-mail address: susianeallgayer@gmail.com (S. Allgayer).
An 18-year-old female patient presented with the chief
complaint of gummy smile. The facial photographs showed exces-
sive gingival display on smiling, slightly convex profile, and
incompetent lip. When the patient smiled, she showed more than 4
mm of gingival exposure in the incisor region and more than 6 mm
in the posterior region (Figs. 1 and 2). The intraoral examination
revealed Class I molar relationship on the right side and one-half
unit Class II relationship on the left side, little mandibular arch
crowding, 4-mm overjet, and moderately deep over bite, and the
maxillary midline was deviated 3 mm to the right.
Cephalometric analysis showed a skeletal Class I relationship
with an A point, nasion, B point angle (ANB) of 2
and an excess of
dentoalveolar height on the molars and incisors. The McNamara
analysis evidenced maxillary excess (A to nasion perpendicular [A-
NPerp] 2 mm). Despite the dentoalveolar maxillary excess, the
nasolabial angle was obtuse (nasolabial angle 127
). The mandible
presented excessive length (condylion to point A [Co-A] 89, con-
dylion to the anatomic point Gnathion [Co-Gn] 120 mm, max-
illomandibular difference of 31 mm) and was protruded in relation
to the cranial base (from the pogonion to the nasion perpendicular
[Pog-NPerp] 2 mm). However, this was masked by the LAFH, which
was also very increased (Lower Anterior Facial Height [LAFH] 76
),
thus contributing to the vertical pattern. The maxillary and
mandibular incisors were buccally tipped and protruded (distance

2212-4438/$ e see front matter Ó 2013 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2013.02.005
e100 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106

Fig. 1. (AeI) Pretreatment facial and intraoral photographs.

between the upper incisor tip and the nasion point A line [1-NA] ¼
9, the angle between the upper incisor and nasion point A line
[1:NA] 25
, distance between the lower incisor tip and the nasion
point B line [1-NB] ¼ 7, the angle between the lower incisor and
nasion point B line [1:NB] 28
, and Incisor Mandibular Plane Angle
[IMPA] ¼ 95
). The radiographic images and tracings are presented
in Figure 3 and the cephalometric measurements in Table 1.
2.1. Treatment objectives
The treatment objectives were 1) to reduce the gummy smile
and protruded profile, and 2) to additionally distalize the
maxillary left teeth, which was needed to correct the maxillary
midline and obtain a good functional Class I molar and canine
relationship.

Fig. 2. (AeE) Initial dental casts.

 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106 e101

Fig. 3. (A) Initial lateral cephalometric radiograph and (B) tracing.

2.2. Treatment alternatives
Three alternatives were presented to the patient to eliminate the
gummy smile: 1) extract the left first premolar to achieve a canine
Class I relationship and correct the dental midline, followed by
maxillary impaction orthognathic surgery to eliminate the gummy
smile and improve the profile; 2) use mini-implants to provide
absolute anchorage to move the entire maxillary dentition apically,
and also move the left posterior teeth distally to obtain a Class I
relationship on that side and allow space to correct the dental
midline; or 3) extract the maxillary first premolars and the
mandibular second premolars, and use a J-hook headgear as
anchorage for retraction and intrusion. The disadvantage was that
the effect of this treatment depended on patient compliance.
The headgear was unacceptable. After a review of the risks and
benefits of the two first options, the patient chose the more
conservative method. The second alternative was elected because
of some advantages of being less invasive and requiring a shorter
treatment time.

2.3. Treatment progress

Table 1
Cephalometric summary
Maxillary first molars were banded with buccal tubes and
Measurement Pretreatment Post-treatment lingual convertible tubes for a removable transpalatal arch. Trans-
SNA 81 79 palatal and lingual arches were placed to counteract buccal crown
SNB 78 77 tipping toward the mini-implants [6]. Mandibular first molars were
ANB 3 þ2
banded and fixed; standard edgewise appliances with 0.022 
1-NA 9 7
1:NA 24 21 0.028-inch slot brackets were bonded in the remaining teeth
1-NB 7 7 (Figs. 4 and 5).
1:NB 29 33 In the mandibular arch, a 2-mm stripping was performed in the
1:1 125 124 anterior region from the mesial surface of the left canine to the
Occl:SN 14 18
GoGn.SN 33 34
mesial surface of the right canine. Both arches were then aligned
S-LS 1 1.5 and leveled beginning with 0.012-inch nickel-titanium archwires
S-LI 2 þ1.5 up to 0.019  0.026-inch stainless steel archwires. At that time, the
Y-axis to FH 56 57 maxillary arch was changed for a 0.0215  0.028-inch stainless steel
NPog.FH 92 91
wire and the transpalatal arch was adjusted in place. Then, two
Angle of convexity 3 þ1.5
WITS þ1 2 mini-implants were placed between the maxillary canines and first
FMA 23 26 premolars and two between the maxillary first and second molars
FMIA 62 57 (1.5 mm in diameter and 6 mm in length [OrtoImplante, Conexão,
IMPA 95 97 São Paulo, Brazil]) (Figs. 4 and 6). An intrusive force of 100g in the
Nasolabial angle 127 128
A-NPerp þ2 1
anterior region and 150g [16] in the posterior region was applied by
Co-A 89 88 nickel-titanium closed coil springs from the mini-implants to the
Co-Gn 120 120 maxillary archwire. In the right side, the coils were tied to the
LAFH 76 76 archwire straight vertically, but in the left side, the coils were tied
Pog-NPerp þ2 þ2
with a posterior vector of force to intrude and distalize the teeth on
ANB, A point, nasion, B point angle; A-NPerp, A to nasion perpendicular; Co, Con- that side.
dylion; LAFH, Lower Anterior Facial Height; FH, Frankfort horizontal plane; FMA, The objective of the full slot maxillary archwire in conjunction
Frankfort mandibular plane angle; FMIA, Frankfort Mandibular Incisor Angle; Gn,
gnathian; Go, gonial; IMPA, incisor to mandibular plane angle; LI, lower lip; LS,
with the transpalatal arch was to control the tendency of maxillary
upper lip; NA, nasion point A; NB, nasion point B; Occl:SN, Occlusal Plane Angle; Pog, teeth to incline in the buccal direction due to the force of coil
pogonion; SNA, sella nasion point A; SNB, sella nasion point B; WITS, Wits appraisal. springs from the mini-implants [6]. The transpalatal arch was
e102 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106
Fig. 4. Intraoral aspects of treatment progress: (A) frontal, (B) lateral left, nickel-titanium closed coil springs on the mini-implants for further maxillary retraction, and (C) occlusal,
maxillary first molars were banded with buccal tubes and lingual convertible tubes for a removable transpalatal arch.
contracted and reinserted in the palatal tubes to annul the buccal
moment generated by the force of the coils. The transpalatal arch
was also adjusted to allow posterior movement of the left teeth.
After adequate intrusion to eliminate the gummy smile after 12
months [4], the left side Class II was nearly corrected and Class II
elastics were necessary to conclude the anteroposterior correction
on that side. Intermaxillary elastics were applied with 0.018-inch
stainless steel wires in the brackets for better interdigitation of
occlusion. Elastic chain was used to correct the maxillary midline.
The mini-implants remained stable during treatment and were
removed under topical anesthesia. After debonding and debanding,
a canine-to-canine lingual retainer was bonded in the mandibular
arch, and a removable circumferential retainer was placed in the
maxillary arch. The total active treatment time was 32 months
(Figs. 7 and 8).
2.4. Treatment results
The gummy smile was eliminated, and in full smile view, the
patient showed no more than 1 to 2 mm of gingiva. The post-
treatment photographs and dental casts demonstrated Class I
canine and molar relationships with normal over bite and overjet,
and the dental midlines were coincident to each other and with the
facial midline (Figs. 7 and 8). The cephalometric analysis (Table 1)
and superimposition showed intrusion and distalization of maxil-
lary molars, which caused self-rotation of the mandible. The
maxillary incisors were intruded and retracted. The maxillary
anterior alveolar bone and gingiva were moved lingually and
upward by tooth movement (Fig. 9C and 9D). The post-treatment
cephalogram and panoramic radiograph (Fig. 9A and 9B) evidenced
mild root resorptions within acceptable parameters compatible
with the extent of movement.
3. Discussion
In this case, the mini-implants remained stable during the time
of intrusive force application (12 months) (Fig. 4A and 4B). The
treatment time (32 months) was a little longer because of one-half
Class II correction on the left side. The molar was distalized to
correct the one-half Class II and intruded (Fig. 9C and 9D). The
mandible presented counterclockwise rotation during treatment, as
observed on the tracing at treatment completion (red line). The
protruded profile was straightened with this movement (Fig. 9C). In
an ideal situation, about 1 to 2 mm of gingiva will be apparent when
the patient smiles (Fig. 7D) [1,18,20,21]. However, some patients
show more than 2 mm of gingival tissue. Although this situation
does not produce any pathological sequelae, it may appear unaes-
thetic (Fig. 1C and 1D) [1].
Excessive gingival display can be divided into several categories
according to etiologic factors [1e4]. The patient presented lip
incompetence at treatment onset (Fig. 1B). Many factors are
involved in lip protrusion, and it is obvious that the amount of
protrusion can be controlled by various orthodontic and surgical
procedures. Retracting or protracting the incisors surgically or
orthodontically can achieve concordant lip position [22]. Super-
impositions of pretreatment and post-treatment cephalometric
tracings showed significant improvement in teeth inclinations and
angulationsd1-NA ¼ 7, 1:NA 25
, 1-NB ¼ 5, 1:NB 29
, and IMPA¼
96
(Fig. 9Be9D)dand the lips became competent (Fig. 7B) [6].
Because of the significant amount of tooth movement and intru-
sion, minor root resorption of the maxillary and mandibular incisor
root apices could be seen in the post-treatment panoramic radio-
graph (Fig. 9A) [11].
When gummy smile is found in adults with long-face syndrome,
caused by excessive vertical maxillary growth, orthognathic surgery
is generally required to intrude the maxilla and eliminate the
excessive gingival display [1,2,6,8,9,18,21]. The increase in vertical
facial height may be confirmed by cephalometric analysis [3].
Specifically in this patient, the LAFH was 76
at treatment onset.
Potential risks of jaw surgery include excessive hemorrhage,
infection, loss of tooth vitality, and periodontal loss, as well as risks
inherent to anesthesia [6]. Because the risks and treatment costs
could be high, our patient was reluctant to undergo surgery. She
was willing to accept a compromised result [19].
The decisions of adult patients to pursue nonsurgical treatment
are also based on their nasal profiles. In this patient, the nasolabial
 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106 e103

Fig. 5. Treatment progress. Scheme of procedures: maxillary first molars were banded with buccal tubes and lingual convertible tubes for a removable transpalatal arch.

angle was extremely obtuse before treatment onset (nasolabial
angle 127
) (Fig. 9C). As discussed, impaction of the anterior
segment by Le Fort I tends to increase nasal alar width and elevate
the nasal tip with an increase in nasolabial angle, worsening the
patient’s nasal profile in that case [4,6,7].
Orthodontic mini-implants have revolutionized orthodontic
anchorage and biomechanics by making anchorage perfectly
stable [14]. Mini-implants have been used to intrude incisors
since 1983, when Creekmore and Eklund [23] reported using
a metal implant to correct a deep over bite. Treatment of exces-
sive gingival display using mini-screw anchorage has the
following advantages over orthodontic treatment combined with
orthognathic surgery: fewer risks, simpler orthodontic biome-
chanics, less patient discomfort, increased cost effectiveness, and
no increase in alar base width. Mini-implants were placed
between the maxillary canines and first premolars and between
the maxillary first and second molars combined with nickel-
titanium closed-coil springs to provide a continuous total force
for indirect anchorage application [6]. A horizontal force was
applied for retraction of the protrusive anterior dentoalveolar
complex, and vertical force for intrusion of the anterior teeth
[18].
This case report demonstrated that the use of miniscrew
anchorage for maxillary intrusion is a viable alternative to
e104 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106
Fig. 6. Panoramic radiograph.
orthognathic surgery for some patients who present with the chief
complaint of gummy smile and who refuse surgery [6]. An
aesthetic crown-lengthening procedure was indicated to improve
the aspect of maxillary anterior teeth, but the patient refused this
option because she was satisfied with the results achieved (Fig. 7C
and 7D).
In the orthodontic clinic, although titanium miniplates and
dental implants have also been successfully used for tooth intrusion
[10,24], the miniscrew has the advantages of immediate loading,
multiple placement sites, uncomplicated placement and removal
procedures, and minimal expense for patients [16]. A mini-implant
for orthodontic anchorage should be small enough to place in any
areas of alveolar bone, even apical bone (Fig. 4B). The surgical
procedure should be easy enough for an orthodontist or general
Fig. 7. (AeI) Post-treatment facial and intraoral photographs.
dentist to perform and minor enough for rapid healing. The implant
should be easily removable after orthodontic treatment [12].
Minimal patient cooperation was required except for good oral
hygiene [13,24]. The mini-implants remained stable during all the
active treatment time and were demonstrated to be an adequate
anchorage option for the orthodontic treatment of an adult patient
with gummy smile. Moreover, they did not require patient
compliance.
4. Conclusions
The maxillary molars were intruded and distalized to correct
the maxillary midline and obtain a good functional Class I molar
and canine relationship. The maxillary incisors were intruded and
retracted, allowing the alveolar bone and gingiva to move
lingually and upward by tooth movement. The treatment objec-
tives were achieved with reduction of the gummy smile and
protruded profile. Individualized diagnosis and treatment plan-
ning are essential to appropriately address each patient’s needs
and goals. Each patient should be individually evaluated to
determine if a nonsurgical approach may provide acceptable
correction. The orthodontic treatment with skeletal anchorage
cannot replace orthognathic surgery; however, considering the
costs and risks of surgery, it may be used as an alternative for
selected cases and if a patient refuses surgery, as demonstrated in
this successful case of correction. Further studies on mini-
implants for orthodontic anchorage in the management of
gummy smile are warranted. Prospective clinical studies are
necessary with this proposed protocol.
 C.A. Estevanell Tavares et al. / Journal of the World Federation of Orthodontists 2 (2013) e99ee106 e105

Fig. 8. (AeE) Final dental casts.

Fig. 9. Radiographs and tracing at treatment completion: (A) panoramic; (B) radiograph lateral cephalogram superimposition of cephalometric tracings before treatment (black line)
and after treatment completion (red line) on (C) sella-nasion plane at sella to evaluate both bone and soft tissue profile changes; and on (D) palatal plane at ANS to evaluate alveolar
remodeling and tooth movement.

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