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Gummysmile 210517040945
Gummysmile 210517040945
Gummysmile 210517040945
Management of
Gummy Smile
Arun Bosco Jerald
2018 batch
Contents
• Introduction • Treatment Modalities
• Etiology • Orthopaedic
• Clinical evaluation • Restorative And Periodontal
• Orthodontic
• Smile evaluation
• Surgical Correction
• Components of a balanced smile
• Conclusion
• Periodontal evaluation
• References
• Smile Analysis
Introduction
• The smile is a complex facial expression that is associated with beauty.
• Facial expressions and the smile are key components for non verbal
communication
Facial Balance:
• Its an assessment of vertical jaw relationship
• Three ratios
First ratio: “Vertical thirds”
• Upper third: Trichion to Glabella
• Middle third: Glabella to Subnasale
• Lower third: Subnasale to Soft tissue Menton
Third ratio:
• Subnasale to Vermillion cutaneous border of L/L : Vermillion
cutaneous border of L/L to Soft tissue Menton
• The ratio should be 1:1
❖Evaluation of lip posture and incisor prominence
• Excessive separation of the lips at rest is called lip incompetence.
• The general guideline that holds for all racial groups is that lip
separation at rest should be not more than 3-4 mm
• Increased interlabial gap is seen in:
• Anatomic short upper lip
• Vertical maxillary excess
• Mandibular protrusion with open bite
• Decreased interlabial gap is seen in:
• Vertical maxillary deficiency
• Anatomically long upper lip
• Mandibular retrusion with deep bite
❖Lip prominence
• Is evaluated by observing the distance that each lip projects forward
from soft tissue points A and B.
• Lip prominence of more than 2 to 3 mm in the presence of lip
incompetence indicates dentoalveolar protrusion.
• Lip prominence in the context of the relationship
of the lips to the nose and chin can be assessed by
drawing the E-line (esthetic line) from the nose to
the chin and to look at how the lips relate to this
line.
• The guideline is that they should be on or slightly
in front of the E-line. (Proffit)
• Lower lip should be 0-2mm away (Reyneke)
Smile evaluation
Basic Classification of the Smile
• Posed or Social Smile
• Voluntary
• Static
• Not elicited by emotion
• Fairly Reproducible
• Un-Posed or Emotional Smile
• Involuntary & Spontaneous
• Dynamic
• Elicited by joy or mirth
• Hardly Reproducible
• Characterized by more lip elevation than posed smile
Three styles of smile - Rubin L.R (Plast. Reconstr. Surg, 1974)
• The cuspid /commissure smile,
• The complex / full-denture smile, and
• The Mona Lisa smile
• A normal gingival display between the inferior border of the upper lip
and the gingival margin of the maxillary anterior teeth during a posed
smile is 1 -2 mm
• The maxillary anterior teeth should be completely displayed during a
full smile .
Tjan, Miller and The performed a semi quantitative study of smil-line
variations in 1984
• The lip line is the amount of vertical tooth exposure in smiling - ie,
the height of the upper lip relative to the maxillary central incisors.
• As a general guideline, the lip line is optimal when the upper lip reaches
the gingival margin, displaying the total cervicoincisal length of the
maxillary central incisors, along with the interproximal gingivae.
• Female lip lines are an average 1.5mm higher than male lip lines,
1-2mm of gingival display at maximum smile could be considered
normal for females.
• Dental professionals have been conditioned to see a “gummy smile” as
undesirable, but some gingival display is certainly acceptable, and is
even considered a sign of youthful appearance.
(Peck S, Peck L and Kataja; AO- 1992)
• The starting point of a smile is the lip line at rest, with an average
maxillary incisor display of 1.91mm in men and nearly twice that
amount, 3.40mm, in women. (Vig and Brundo, J. Prost. Dent, 1978)
• With aging, there is a gradual decrease in exposure of the maxillary
incisors at rest and, to a much lesser degree, in smiling.
• This steady decline in maxillary tooth exposure at rest is accompanied
by an increase in mandibular incisor display.
• Peck S, Peck L and Kataja; AO- 1992
• To measure the upper lip smile line:
• A vertical axis graduated in millimeters is visualized along the
soft tissue facial midline. A perpendicular, tangent to the cervical
margin of the upper central incisor defines the horizontal axis.
• The amount of vertical exposure in smiling depends on the following
six factors.
• Upper Lip Length
• Lip Elevation
• Vertical Maxillary Height
• Crown Height
• Vertical Dental Height
• Incisor Inclination
i) Upper Lip Length
• The normal lip length at rest, as measured from Subnasale to the most
inferior portion of the upper lip at the midline is 20 ± 2 mm for females
and 22 ± 2 mm for males (Reyneke J P)
UPPER LIP LENGTHS FROM VARIOUS STUDIES (mm)
Study Male Female
Burstone C J (Am. J. Orthod. 1967) 23.8 ± 1.5 20.1 ± 1.9
Farkas et al. (Am. J. Orthod. 1984) 21.8 ± 2.2 19.6 ± 2.4
Powell and Humphreys (1984) 23.8 ± 1.5 20.1 ± 1
Wolford L M (Plast. Reconstr. Surg, 1988) 22 ± 2 20 ± 2
Peck S, Peck L. and Kataja (Am. J. Orthod. 1992) 23.4 ± 2.5 21.2 ± 2.4
Arnett G.W. and Bergman (Am. J. Orthod. 1993) 19-22
• What is significant, however, is the relationship of the upper lip to the
maxillary incisors and to the commissures of the mouth.
• Lip length should be roughly equal to the commissure height, which is
the vertical distance between the commissure and a horizontal line
from subnasale.
• It is not easy to alter commissure height, but lip lengthening is possible
with lip surgery, either as a single procedure or in combination with a
Le Fort I osteotomy.
• In adolescents, a short upper lip relative to commissure height could be
considered normal because of the lip lengthening that continues even
after vertical skeletal growth is complete.
• It is interesting to note that a short upper lip is not always associated
with a high lip line; on the contrary, the upper lip was found to be
longer in a gingival-display group than in a non-displaying sample.
Short upper lip
• When lip length is 18mm or less
• In addition there will be:
• Increased interlabial gap
• Increased incisor exposure
• Normal lower face height
ii) Lip Elevation
• In smiling, the upper lip is elevated by about 80% of its original length,
displaying 10mm of the maxillary incisors.
• Women have 3.5% more lip elevation than men.
(Rigsbee, Sperry and BeGole; Int. J. Adult Orthod. Orthog. Surg.,1988)
• Actually, there is considerable individual variability in upper lip
elevation from rest position to the full smile, ranging from 2-12mm,
with an average of 7-8mm.
(Sarver D.M. and Weissman S.M. Angle Orthod.,1991)
• If a gingival smile is caused by a hypermobile lip, it would be a mistake
to correct it with aggressive incisor intrusion or maxillary impaction
surgery, because that would result in little or no incisor display at rest
and thus make the patient look older.
• Excessive lip elevation should therefore be recognized as a limiting
factor
• Likewise, if a low lip line is due to a hypomobile lip, extensive incisor
extrusion would result in an overbite with excessive incisor display at
rest.
iii) Vertical Maxillary Height
• When upper lip length and mobility are normal, a gingival smile with
excessive incisor display at rest can be attributed to vertical maxillary
excess.
• This kind of “skeletal” gingival smile is generally associated with
excessive lower facial height.
• Conversely, a low lip line with no incisor display at rest is “skeletal”
when associated with inadequate lower facial height due to a vertically
deficient maxilla.
• The best reference for impacting or lengthening the maxilla is the
incisor display at rest, taking upper lip length and any incisor attrition
into account.
• The full smile does not make a good reference, partly because of the
individual variation in lip mobility.
• A short upper lip should not be treated by shortening the maxilla
unless the facial outline can accommodate such a change.
• It should also be noted that in maxillary impaction, the upper lip
shortens by as much as 50% of the surgical skeletal intrusion. (Sarver
D.M. and Weissman S.M. Angle Orthod.,1991)
iv) Crown Height
• The average vertical height of the maxillary central incisor is 10.6mm in
males and 9.8mm in females.
• A short crown can be due to attrition or excessive gingival encroachment.
• If there is little or no incisor display at rest, but the lip line is normal in
smiling, the crown height can be increased incisally with cosmetic
dentistry.
• A gingivectomy or a crown-lengthening procedure with crestal bone
removal is recommended when short clinical crowns are associated with a
gingival smile and a normal incisor display at rest.
v) Vertical Dental Height
• A deep bite should be corrected by maxillary incisor intrusion in a pt
with excessive incisor display at rest, but with posterior extrusion
and/or lower incisor intrusion in a pt with a normal lip line at rest.
• The opposite applies to an open bite, which should be corrected by
maxillary incisor extrusion if there is inadequate incisor display at rest,
but with posterior intrusion and/or lower incisor extrusion if the lip
line is normal at rest.
vi) Incisor Inclination
• Proclined maxillary incisors, whether in a Class II, division 1 mo or in
a Class III compensation, tend to reduce the incisor display at rest and
in smiling.
• Uprighted or retroclined maxillary incisors, as seen in Class II, division
2 mo or after orthodontic retraction without torque control, tend to
increase the incisor display.
• Maxillary incisor inclination can best be assessed on profile and oblique
smiling photographs, which should become standard orthodontic
records.
2. Smile Arc
• The upper lip curvature is assessed from the central position to the
corner of the mouth in smiling.
• It is upward when the corner of the mouth is higher than the central
position, straight when the corner of the mouth and the central
position are at the same level, and downward when the corner of the
mouth is lower than the central position.
4. Lateral Negative Space
• In a patient with hyperactive upper lip ,the lip may translate 1.5 to 2
times more than the normal distance
Lip repositioning technique
• The procedure restricts the muscle pull of the elevator lip muscles by
shortening the vestibule, thus reducing the gingival display while
smiling
• Partial thickness incision at muco gingival junction.
• 2nd incision parallel to it at 10-12 mm on labial mucosa.
• Both the incisions are approximated at mesial line angles of maxillary
molars.
• Tissue excision should be double the amount of gingival display.
• Effective procedure to reduce gingival display by positioning the upper
lip in a coronal location
Short
clinical CROWN LENGTHENING
crown
COMBINATION
Average vertical height of
maxillary incisor:
•10.6mm in males
•9.8mm in females.
Loss of torque or palatally tipped maxillary
incisors Loss of torque
Increased incisal
display
MANAGEMENT :
If iatrogenic – incorporation of torque in the wire
Anterior dentoalveolar extrusion
• Overeruption of the maxillary incisors with their dentogingival
complex leads to a more coronal position of the gingival margins and
excessive gingival display.
• In cases with deep bite, there is usually discrepancy in the occlusal
plane between the anterior and posterior segments
MANAGEMENT
Surgical periodontal
Orthodontic An interdisciplinary
correction with or
intrusion of the comprehensive
without adjunctive
involved teeth treatment plan.
restorative therapy,
Orthodontic intrusion
• Intrusion refers to the apical movement of the geometric center of the
root (Centroid) with respect to the occlusal plane or plane based on the
long axis of the tooth. (Burstone)
• Most useful for patients who are in either the mixed or early
permanent dentition period.
• Three different mechanical arrangements are commonly used, each
based on the same mechanical principle: uprighting and distal tipping
of the molars, pitted against intrusion of the incisors.
• A classic version of this approach was seen in the first stage of the
Begg technique in which the premolar teeth were bypassed and only a
loose tie was made to the canine.
• The same effect can be produced by using the edgewise appliance, if
the premolars and canines are bypassed with a 2 × 4 appliance (only
two molars and four incisors included in the appliance setup) or if
brackets on premolars simply do not have the main archwire tied in.
• Ricketts’ utility arch:
formed from rectangular wire; can be placed into the brackets with
slight labial root torque to control the inclination of the incisors as
they move labially while intruding.
• Successful use of any type of bypass arch for leveling requires keeping
the forces light, accomplished by selecting a small-diameter archwire,
and by using a long span ie. b/n the 1st molars and the incisors.
• Wire heavier than 16-mil steel should not be used, and a relatively soft
16 × 16 cobalt–chromium wire is recommended for utility arches to
prevent heavy forces from being developed.
• A more modern recommendation would be 16 × 22 β-Ti wire.
• Whether an 18- or 22-slot appliance is used, the bypass arch should not
be stiffer than 16-mil steel.
• Two weaknesses of the bypass arch systems limit the
amount of true intrusion that can be obtained:
• Except for some applications of the utility arch, only
the 1st molar is available as anchorage.
• The intrusive force against the incisors is applied
anterior to the center of resistance, and therefore the
incisors tend to tip forward as they intrude
• Tying an intrusion arch distal to the midline (b/n the lateral incisor
and canine) moves the line of force more posteriorly and closer to
the center of resistance eliminates the moment that causes facial
tipping of the teeth as they intrude.
• An anchor bend at the molar in a bypass arch creates a space-closing
effect that somewhat restrains forward incisor movement, but this also
tends to bring the molar forward, straining the posterior anchorage.
BURSTONE’S SEGMENTAL ARCH:
• Triple tube molar attachments are used
• Heavy stainless steel anterior segment (0.021x0.025 ss) with TMA tip
back springs (0.017x0.025) and
• Passive segmented posterior stabilizing units (0.019x0.025) are placed.
K-SIR ARCH
• Simultaneous intrusion and retraction of the six anterior by using non-
frictional loop mechanics, which was developed by Dr. Varun Kalra,
based on space closure mechanics advocated by Dr. C. J. Burstone.
• A continuous 0.19" x 0.25" TMA archwire with closed 7mm x 2mm U-
loops at extraction sites.
• 90˚ V-bend is placed in the archwire at the level of each U-loop by
placing Centered V – bends which create two equal and opposite
moments.
• A 60˚ V-bend located posterior to the center of inter bracket distance
to augments molar anchorage during intrusion of anterior teeth.
• And 20˚ antirotation bends are placed to prevent molar rotations.
• 0.019" x 0.025" TMA provides sufficient strength to resist distortion,
but enough stiffness to generate required moments.
• At the same time TMA has low forces, low load deflection rate and
high range of activation
CONNECTICUT INTRUSION ARCH
• Fabricated from a nickel titanium alloy to provide the advantages of
shape memory, springback, and light, continuous force distribution.
• It incorporates the characteristics of the utility arch as well as those of
the conventional intrusion arch.
• It is preformed with the appropriate bends necessary for easy insertion
and use.
• Two wire sizes are available: .016" X .022" and .017" X .025".
• The maxillary and mandibular versions have anterior dimensions of
34mm and 28mm, respectively.
• Although in most cases the wire is not directly ligated into the bracket
slots, the anterior wire dimension is adequate to allow for it.
Segmented Archwires for Intrusion
• Many patients with present with moderate to deep bites requiring pure
intrusion of the anterior teeth to level the occlusal plane.
• Unless the deep bite is so extreme that absolute anchorage is needed, it
may be inadvisable to place miniscrews simultaneously in both arches
in young patients.
• In these instances miniscrews can be used to reinforce conventional
orthodontic mechanics.
1) Bilateral implants for en-masse intrusion of anteriors:
• The implants used are 1.3 mm in diameter and 8 mm in length.
• Bone contacts at insertion influences the primary stability of the
implants.
• Increasing the diameter and length of the implant allows greater
surface area contact between the bone and implant.
• It’s important to have a mechanical interdigitation between implants
and cortical bone
Placement Site:
• the alveolar bone between lateral incisor and canine bilaterally at the
level of attached gingiva
Clinical set up
1. The maxillary dental anterior segment should extend from distal of
canines on either side.
A 21x 25 stainless steel arch is placed in all the three segments.
In the anterior segment, hooks are placed between lateral incisor and
canine bilaterally.
This is followed by placement of mini implants which are loaded
immediately.
2. A calibrated Dontrix gauge is used to measure the amount of
intrusive force being applied.
45 gms of intrusive force is applied per side using a pre-stretched
elastic chain i.e. a total of 90 gms of intrusive force is applied to the six
anterior teeth.
3. A ligature wire lace back is tied extending from the maxillary molar
hook to the tag incorporated distal to canine in the anterior segment.
• True intrusion takes place when forces are directed through the center
of resistance.
• If the intrusive force is applied anterior to the center of resistance of a
segment, it results in flaring of the teeth.
• The implants are placed between the canine and the lateral incisors
bilaterally so the point of application of force is closer to the center of
resistance of anterior segment.
• However, directing the force through the center of resistance is not
possible in a clinical set up.
• As a result some amount of flaring is inevitable with any intrusive
mechanics.
• To prevent a steel ligature lace back from the molar hook to distal of
canine should be placed.
• This is just enough to prevent flaring, without having any reciprocal
mesializing effects on the molars and also directs the resultant force
vector close to the center of resistance.
2) Mid-implant for intrusion of maxillary incisors
• The implants used are 1.3 mm in diameter and 8 mm in length.
• A stainless steel archwire with utility design engaging four incisors and
two molar, bypassing the canine and premolar is used made of
0.017x0.025
• Passive segmented posterior stabilizing unit (0.019x0.025)
• A closed coil spring or a E-chain can be used to deliver force of around
60-70 grams
• There are certain cases where only incisors are extruded and need
intrusion or a clinical situation where the canines have been retracted
and the incisors need intrusion, in such cases a mid-implant below the
anterior nasal spine is placed.
• Creekmore T D and Eklund published a case report was using a
vitallium implant for anchorage while intruding the upper anterior
teeth.
• The vitallium screw was inserted just below the anterior nasal spine
and after a healing period of 10 days, an elastic thread was tied from
the head of the screw to the archwire. .
• Ohnishi et al described the correction of significant deep bites using
mini-implants as anchorage for the intrusion of the upper anterior
segment.
• Miniimplants were placed in between the roots of maxillary central
incisors
High pull
headgear with or Orthognathic
without maxillary surgery
splint
It provides:
1. Decreased gonial angle
2. Redirection of condylar growth
3. Increased posterior height.
Extractions and space closure mechanics:
• Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91–
100