CASE REPORT

Orthodontic correction of a skeletal Class

II malocclusion with severe gummy smile
by total intrusion of the maxillary
dentition
Peiqi Wang, Jiajun Chen, Xinghai Wang, Ding Bai, and Yongwen Guo
Chengdu, Sichuan, China

A 22-year-old woman visited the hospital complaining of lip protrusion, crowded teeth, and a gummy smile. The
clinical examination showed a convex profile with a hyperdivergent mandible and a severe gummy smile in both
anterior and posterior regions. The unstable mandible position was considered during treatment planning, and a
targeted mechanic system was carefully designed. Temporary skeletal anchorage devices in the posterior
dental region and a transpalatal arch were introduced as anchorage for the intrusion of the entire maxillary denti-
tion and controlled retraction of the anterior teeth. Based on effective and simple mechanisms, we successfully
eliminated the severe gummy smile and improved the facial aesthetics with the aid of conventional appliances.
This approach provided an alternative option to orthognathic surgery or bulky invasive miniscrews for treatment
of skeletal Class II malocclusion with severe gummy smile. (Am J Orthod Dentofacial Orthop 2022;162:777-92)

G
ummy smile, a status described as the visibility of
an excessive amount of gingiva during smiling,
can occur as a result of various intraoral or ex-
traoral etiologies involving soft tissue, dentoalveolar,
and skeletal types.1,2 Herein, conducting complete ana-
lyses and making proper diagnoses and treatment plans
is fundamental. When a skeletal component causes the
gummy smile (ie, vertical maxillary excess [VME]), the
treatment to reduce excessive gingival display may not
be satisfactory with adjunctive approaches such as bot-
ulinum toxin injection or crown lengthening procedure.
Moreover, VME is also often accompanied by a retruded
mandible with clockwise rotation and skeletal Class II
From the State Key Laboratory of Oral Diseases, and National Clinical Research
Center for Oral Diseases, and Department of Orthodontics, West China Hospital
of Stomatology, Sichuan University, Chengdu, Sichuan, China.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This study is supported by the National Natural Science Foundation of China (No.
32171308), Science and Technology Project of Sichuan Province, China (No.
2021YJ0150), and Technological Innovation R&D Project of Chengdu, China
(No. 2021-YF05-02097-SN).
Address correspondence to: Yongwen Guo, State Key Laboratory of Oral Diseases,
and National Clinical Research Center for Oral Diseases, and Department of Or-
thodontics, West China Hospital of Stomatology, Sichuan University, No. 14, 3rd
Section of Renmin Nan Rd, Chengdu 610041, Sichuan, China; e-mail,
orthoguo@126.com.
Submitted, November 2020; revised and accepted, May 2021.
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2021.05.019
malocclusion.3 In such patients, reduction of the maxil-
lary vertical dimension by LeFort I osteotomy is generally
indicated.4 However, in recent years, the introduction of
the skeletal anchorage system has expanded the spec-
trum of orthodontic treatment. Temporary skeletal
anchorage devices (TSADs) are now frequently used for
orthodontic tooth movement and have been implicated
in correcting gummy smile and skeletal Class II discrep-
ancies by assisting the 3-dimensional controls.5-7
Generally, patients with obvious gingival smiles need
TSADs in the anterior region to achieve direct intrusion
of the anterior teeth.8 For patients in which total intru-
sion of the maxillary dentition is demanded, 6 TSADs or
bulky devices are often required on the labial side of the
anterior dentition and both buccal and palatal sides of
the posterior dentition bilaterally.5,7,9,10 However,
although TSADs can provide stationary anchorages for
various tooth movements and are alleged to be mini-
mally invasive, their clinical use may include limitations,
such as the risk of root damage on contacting and oral
tissue irritation, and some patients may find the involve-
ment of multiple TSADs traumatic and expensive and
thus are reluctant to accept.11 More importantly, the
whole mechanical system would be affected in a system
with so many implants. Therefore, the treatment effect
could be diminished even when only a single miniscrew
loosens.11-13
777
778
Fig 1. Pretreatment facial and intraoral photographs.
In this patient, we presented anchorage for retraction
of maxillary anterior teeth, and only 2 TSADs achieved to-
tal intrusion of the maxillary dentition in the buccal sides
of the maxillary posterior region, and the maxillary trans-
verse width was stabilized through the application of a
conventional transpalatal arch (TPA). Moreover, we
considered the change in the mandibular position and
made the treatment design on this basis. Favorable treat-
ment outcomes, including the correction of gummy smile
and improvement of the facial profile, were achieved
through an accurate diagnosis and appropriate treatment
plan using targeted and effective mechanisms.
DIAGNOSIS AND ETIOLOGY
The patient, a 22-year-old Chinese woman, came to
our hospital with chief complaints of lip protrusion,
crowded teeth, and a gummy smile. She claimed no
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Wang et al
history of dental trauma and orthodontic or surgical
treatments, and her family history revealed a similar
facial profile to her father. In addition, she denied
long-term medication and bad oral habits of any type.
The photographs taken before treatment showed a
convex profile, with a hyperdivergent mandible and an
increased lower facial height (Fig 1), which could be a
prognostic characteristic relating to unfavorable treat-
ment outcomes and poor stability.14 Protrusive upper
and lower lips exceeding the E-line and strain in the cir-
cumoral musculature on lip closure were also observed.
Facial symmetry was revealed, whereas the maxillary
and mandibular dental midlines were shifted to the right
by 1.5 mm on the basis of the facial midline determined
by the bipupillar perpendicular midline bisector. The in-
traoral photographs and study casts (Fig 2) exhibited
moderate crowding of the mandibular teeth, Class II
Wang et al 779

Fig 2. Pretreatment study casts: A, Casts in centric occlusion; B, Mounted casts on the simple hinge
articulator with a wax record taken by bilateral manipulation; C, Mounted casts on the simple hinge
articulator in occlusion revealed by bilateral manipulation; D, Digital scan of the mounted casts in
occlusion revealed by bilateral manipulation.

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molar relationship, Class II canine and premolar relation-
ship, and a normal overbite and deep overjet. Clinical ex-
amination of the temporomandibular joint (TMJ) was
guided by diagnostic criteria for temporomandibular
disorders (TMD),15 revealing no TMD-related symptoms,
such as pain or click at rest or during mouth movement,
and limited or shifted mouth opening. Specifically, no
discomfort or pain was observed in the patient’s muscles
at rest, during mastication, or on palpation. However,
bilateral manipulation of the mandible revealed the ex-
istence of a dual bite, and the casts were mounted in oc-
clusion with the physiological position of the mandible
as indicated by the manipulation (Fig 2).16 Mounted
casts exhibited more severe Class II canine, premolar,
and molar relationships and a larger overjet than when
evaluated in the patient’s natural occlusion.
Panoramic and cephalometric radiographs were
taken before treatment (Fig 3). The existence of mesially
impacted mandibular third molars, relatively small con-
dyles with cortical continuity, and short ramal height
could be seen on both sides. The lateral cephalometric
analysis (Table) and cephalometric tracing (Fig 3, B) re-
vealed an evident skeletal Class II relationship with a ret-
ruded mandible (ANB, 8.7 ; SNA, 76.0 ; SNB, 67.3 ) and
a hyperdivergent vertical pattern (PFH/AFH, 56.2%; SN-
MP, 53.0 ). The inclinations of the maxillary and
mandibular incisors were within the normal range (U1-
SN, 102.2 ; IMPA, 98.2 ). VME was evident in both
the anterior and posterior dentition (U1-PP, 33.62
mm; U6-PP, 25.19 mm).
TREATMENT OBJECTIVES
The treatment objectives were to (1) reduce excessive
gingival display and correct the gummy smile by the to-
tal intrusion of the maxillary arch, (2) improve the
convex Class II facial profile via retraction of the maxil-
lary anterior dentition and counterclockwise rotation of
the mandible, (3) create a satisfactory Class I occlusion,
(4) achieve an optimal occlusion with appropriate overjet
and overbite and a stable mandible position, and (5) co-
ordinate the dental midlines.
TREATMENT ALTERNATIVES
Two alternatives were presented to the patient. The
first option was combined surgical and orthodontic
treatment, which included LeFort I osteotomy for
maxilla upward and backward movement and bilateral
sagittal split ramus osteotomy for mandibular advance-
ment and counterclockwise rotation. This option could
fundamentally resolve the skeletal discrepancy and effi-
ciently alleviate the gummy smile. The second option
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Wang et al
was TSADs-assisted camouflage orthodontic treatment
with extraction of the maxillary first and mandibular sec-
ond premolars. Total maxillary dentition intrusion and
controlled retraction of maxillary anterior teeth assisted
by TSADs formed archwires, and TPA was designed to
help reduce excessive gingival display, coordinate the
anterior overjet, and achieve counterclockwise rotation
of the mandible, which would be beneficial to the
improvement of the facial esthetics via compensation
of skeletal discrepancy. The patient refused the surgical
treatment and thus decided on the second option.
TREATMENT PROGRESS
Before bracket bonding, maxillary first premolars
and mandibular second premolars were extracted.
Four mini-implants (1.4 mm in diameter; 8 mm in
length; Ormco Corp, Glendora, Calif) were initially in-
serted into the buccal alveolar bone at the height of
the vestibular groove bottom between the first molars
and second premolars bilaterally in both maxillary
and mandibular arches for sagittal and vertical
anchorage control. The maxillary TSADs were designed
to facilitate maxillary intrusion and provide maximum
anchorage for anterior tooth retraction, whereas
the mandibular TSADs were mainly used to prevent
the extrusion and ideally assist the intrusion of the
mandibular molars. Meanwhile, a 1.2-mm diameter
TPA was placed on the maxillary first molars, 8 mm
from the palatal mucosa, to stabilize the transverse
width and prevent buccal flaring of the molars during
intrusion (Fig 4). The TPA loop seemed more distant
from the palatal mucosa than usual because the patient
had a relatively high palatal vault, and we anticipated
tongue pressure during swallowing to facilitate the
intrusion of the molars, which would be more effective
as the distance of the loop to the palatal mucosa
increased.17,18 The patient got used to the loop and
claimed no discomfort in 2 weeks after TPA placement.
Both arches were bonded with preadjusted 0.022-in
brackets with MBT prescription (3M Corp, St Paul,
Minn) and were aligned and leveled by sequenced
0.014, 0.016, 0.018, and 0.018 3 0.025-in nickel-
titanium archwires in 6 months. During the alignment
and leveling, the dual bite was eliminated, as indicated
by carefully applied bilateral manipulation of the
mandible,16 and manifested as seemingly severer Class
II relationships compared with the initial natural occlu-
sion (Fig 5, A).16 The patient’s TMJ condition was
closely monitored under the guidance of diagnostic
criteria for TMD15 on every visit throughout the treat-
ment procedure.
Wang et al 781

Fig 3. Pretreatment radiographs: A, Lateral cephalogram; B, Lateral cephalogram tracing; C, Pano-

ramic radiograph.

To provide the intrusive force for the anterior

Table. Pretreatment and posttreatment cephalo-
segment, an accentuated curve of Spee was placed in
metric analysis
the maxillary 0.018 3 0.025-in stainless steel wire.
The shaped archwire also sufficed to avoid the roller Measurement Norm Pretreatment Posttreatment
coaster effect (ie, excess retraction force-caused mesial SNA ( ) 83.1 6 3.6 76.0 74.9
tipping of the posterior teeth, the distal tipping of the SNB ( ) 79.7 6 3.2 67.3 67.5
ANB ( ) 3.5 6 1.7 8.7 7.4
anterior teeth, and following deepening of overbite)
SN-MP ( ) 32.9 6 4.2 53.0 51.3
(Fig 5, A), and thus a small reverse curve of Spee was OP-SN ( ) 19.4 6 4.0 34.2 31.0
also placed in the mandibular archwire. Retraction force S-Go/N-Me (%) 65.9 6 3.8 56.2 57.0
was applied from the long traction hooks on the maxil- U1-L1 ( ) 127.0 6 8.5 107.2 119.9
lary archwire to the TSADs for maximum anchorage and U1-SN ( ) 104.6 6 6.0 102.2 92.7
U1-NA (mm) 4.0 6 2.0 6.3 0.7
controlled movement, ideally bodily movement, of the
IMPA ( ) 93.9 6 6.2 98.2 94.2
maxillary anterior teeth using nickel-titanium closed- L1-NB (mm) 6.0 6 2.0 12.5 9.5
coil springs. Short traction hooks were used on the UL-EP (mm) 1.8 6 1.9 2.0 1.4
mandibular archwire, and retraction force was applied LL-EP (mm) 2.7 6 2.2 8.7 1.0
from the hooks to the buccal tubes of the mandibular Z angle ( ) 70.0 6 5.0 43.98 60.4
first molars. Meanwhile, elastic power chains were
placed bilaterally from TSADs to the posterior part of were used for mesial mandibular molar movement to co-
the archwires between the second premolars and the first ordinate the molar relationship, whereas the mandibular
molars in both maxillary and mandibular arches to create archwire was bonded to mandibular TSADs to coun-
an intrusive vertical force (Fig 5, A and D). During the teract the extrusive force (Fig 5, B). Because there would
15th and 16th months of the treatment, Class II elastics be an increased chance of dual bite with the protraction

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Fig 4. Intraoral photographs at the beginning of active treatment: TSADs were inserted between the
maxillary and mandibular second premolars and first molars on both sides. A banded TPA was placed
on the maxillary first molars.
vector of Class II elastics, we limited the magnitude (3/8-
in, 3.5 oz) and duration (2 months) of traction. At the
16th to 17th month, the 2 mandibular TSADs became
loose—probably because of the mesial movement of
the mandibular molars—and were subsequently
removed. Through the finishing and detailing stage,
both arches were inserted with flexible 0.016-in nickel-
titanium archwires, and relatively light triangular vertical
elastics (1/4-in, 3.5 oz) were used to increase intercuspa-
tion and coordinate the maxillary and mandibular mid-
lines (Fig 5, C).
The overall duration of active treatment was 25
months. Selective grinding was performed to establish
functional occlusion before removing the appliances.
The miniscrews and TPA were removed, and brackets
were debonded. Then, clear retainers were fabricated
for both arches.
TREATMENT RESULTS
A well-aligned dentition, a more stable mandibular
position indicated by bimanual manipulation and radio-
graphic imaging procedures, an attractive smile, and a
more harmonious facial profile were achieved after 25-
month treatment (Fig 6). The patient was very satisfied
with the improvement of her facial esthetics. The lower
facial height was decreased and the facial profile was
significantly improved. The severe gummy smile was
corrected as a result of total maxillary dentition intru-
sion, and the strain in the circumoral musculature on
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Wang et al
lip closure was relaxed. The canine and molar relation-
ships were normalized to Class I malocclusion with a
normal overbite and overjet and coincided with maxil-
lary and mandibular midlines (Fig 7). A functional occlu-
sion with stable posterior support and proper anterior
guidance was established.
The posttreatment panoramic radiograph showed
acceptable root parallelism in both arches with no signif-
icant root resorption (Fig 8, C). The cephalometric anal-
ysis (Table) and superimposition (Fig 9) indicated a
reduction of overjet with an optimal interincisal angle
accompanied by slight lingual tipping of the maxillary
anterior teeth (U1-L1, 119.9 ; U1-SN, 92.7 ; IMPA,
94.2 ). The maxillary anterior and posterior teeth were
intruded toward the palatal plane by approximately 4.0
mm (from 33.62 mm to 29.62 mm) and 2.5 mm (from
25.19 mm to 22.66 mm), respectively (Fig 9, D), which
was comparable or superior to previous patients using
multiple TSADs or bulky devices.19-22 As a result of
the intrusion of the entire maxillary dentition, the
mandible rotated counterclockwise, as indicated by the
decrease of the SN-MP angle from 53.0 to 51.3 and
the ANB angle from 8.7 to 7.4 . The angles only
changed slightly, considering a large amount of intru-
sion. This may be partially attributed to the change of
mandibular position during treatment which was sug-
gested by the backward and upward movement of the
condyles on the posttreatment cephalometric radio-
graph (Figs 8, A and 9). Posttreatment cone-beam
Wang et al 783

Fig 5. Treatment progress: A, Nickel-titanium closed-coil springs on mandibular molars and maxillary
intrusion force applied; B, A combination of nickel-titanium closed-coil and Class II elastics; C, Inter-
maxillary elastics for better occlusion; D, Occlusal photograph and illustration during the retraction
and intrusion of the mandibular arch.

computed tomography scans showed that both condyles
were seated properly in the glenoid fossae, and cortical
continuity of the condylar heads could be seen (Fig 8,
D). The stable occlusion and mandibular position,
attractive smile, and balanced profile achieved with the
orthodontic treatment have been maintained during
the 18-month follow-up period (Figs 10 and 11). Specif-
ically, pretreatment, posttreatment, and postretention
smiling photographs are displayed in Figure 12. The
cephalometric superimposition (Fig 11, B) showed slight
extrusions of the maxillary incisors (0.47 mm) and mo-
lars (0.36 mm), with relapse rates of 11.75% and
14.4%, respectively. This relapse tendency was consid-
ered acceptable because existing literature has indicated
that the 1-year relapse rates after maxillary incisor and
molar intrusion using skeletal anchorage ranged from
26% to 85% and 10% to 27%, respectively.23-28 Long-
term stability of intrusion could also be expected

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784 Wang et al

Fig 6. Posttreatment facial and intraoral photographs.

according to the relapse pattern revealed by some re-
searchers, with around 80% of the total relapse occur-
ring during the first year of retention.27,28
DISCUSSION
Gummy smiles can be classified by etiology into a
dentogingival gummy smile with an altered passive
eruption of teeth, a muscular gummy smile with hy-
peractive elevator muscles, and a dentoalveolar
gummy smile with VME, including a posterior gummy
smile.1 Despite that this patient exhibited hyperactivity
in the lip lifting muscles, the principal factor in her
seemed to be VME because she had an excessive
gingival display both anteriorly and posteriorly, a
dramatically increased anterior lower facial height,
and a steep mandibular plane caused by the clockwise
rotation of the mandible.29 In addition, the patient
also had severe skeletal Class II malocclusion with a
retruded mandible. Orthognathic surgeries have long
been proven to have satisfactory treatment results in
such patients.30,31 Nevertheless, the development of
TSADs has made it possible to successfully correct a
gummy smile concerning VME and camouflage the
skeletal discrepancy without surgery, as previously re-
ported in nonsurgically treated patients with gummy
smile and retruded mandible.20,21,32 Successful cam-
ouflage treatment of skeletal Class II malocclusion
with severe gummy smile relies on the intrusion of
the maxillary dentition, controlled retraction of the
maxillary anterior teeth, and counterclockwise

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Wang et al
Fig 7. Posttreatment study casts.
rotation of the mandible via targeted and effective 3-
dimensional control.
It is crucial to finalize the occlusion in harmony with
the musculoskeletally stable position of the TMJ.33 As
suggested in a 2016 systematic review, skeletal Class II
malocclusion, retrognathic mandible, and hyperdivergent
growth pattern are associated with increased frequency of
disc displacement, TMD signs, and symptoms.34 Our pa-
tient had a skeletal Class II relationship with hyperdiver-
gent facial morphology; therefore, extra attention was
given to her TMJ despite exhibiting no symptoms before
treatment. Indeed, bilateral manipulation16 of the
mandible revealed the unstableness of her mandible posi-
tion, and the casts were mounted accordingly. We
managed to foresee a clockwise rotation during treatment
due to the repositioning of the condyles, which would
result in an aggravated dental and skeletal Class II rela-
tionship and a more receding chin. Herein, the camou-
flage treatment design was carefully made on this basis.
Maxillary first and mandibular second premolars, instead
of maxillary and mandibular first premolars, were ex-
tracted bilaterally to better coordinate the occlusion and
disguise the skeletal problem. This was based on the
fact that compared with the extraction of the first premo-
lars, the extraction of the second premolars generally
brings more mesial movement of the mandibular molars
and less incisal retraction, which favors the coordination
of molar relationship and anterior overjet and overbite,
American Journal of Orthodontics and Dentofacial Orthopedics
785
and avoids further clockwise mandibular rotation.35,36
Maximum anchorage was desirable for the maxilla,
whereas the mandibular teeth called for medium
anchorage to coordinate the sagittal relation of the maxil-
lary and mandibular dentition during the treatment.
As the patient had severe gummy smile mainly
caused by VME, total intrusion of the maxillary arch
and the vertical control of the posterior teeth in both
arches were particularly important. In previous patients
with anterior gummy smiles, TSADs were often inserted
into anterior parts to directly intrude the anterior teeth
and could not provide anchorage for retraction.8 In pa-
tients with an anterior and posterior gummy smile, the
implantation of 6 TSADs or bulky devices was needed
to intrude the entire maxillary arch.5,7,9,10 In such sys-
tems, the 2 miniscrews in the anterior labial segment
are used for the anterior intrusion and help to prevent
the lingual inclination of the anterior teeth during
retraction, whereas the posterior screws facilitate the
intrusion of the posterior segment and retraction of
the anterior teeth as the traction force has a vertical
and a horizontal component. Potential molar buccal
tipping via intrusive force from buccal TSADs can be
prevented by TSADs on the palatal side. Indeed, it is
effective to implement a combined use of multiple
miniscrews, but some patients may still find the poten-
tial invasion and high cost hard to accept. More impor-
tantly, the success of treatment with multiple TSADs
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786 Wang et al

Fig 8. Posttreatment radiographs (taken on the day right before debonding): A, Lateral cephalogram;
B, Lateral cephalogram tracing; C, Panoramic radiograph; D, Cone-beam computed tomography im-
age of both TMJs. L, left TMJ; R, right TMJ.

relies too much on the steadiness and rigidity of the
miniscrews, and the whole mechanic system may break
down even when only 1 screw gets loose.13 Once rein-
serted, the TSADs could bring greater physical, finan-
cial, and psychological burdens to the patients.
For our patient, only 1 screw on each side of the
buccal region of the maxillary posterior dentition was
included to attain the anchorage needed for both ante-
rior teeth retraction and total intrusion of the maxillary
arch (Fig 13, A). The formed archwire with a
compensatory curve in the maxillary arch could create
a favorable intrusive force in the anterior region and
distal end of the arch and an undesired extrusive force
on the premolars and first molars. However, the force
applied by elastic power chains to the miniscrews func-
tioned to withstand the extrusive force resulting from
the archwire and to provide posterior intrusion.
Together, the intrusion of the entire maxillary dentition
was accomplished through the joint effect of the formed
archwire and the posterior TSADs.

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Wang et al 787

Fig 9. Superimposed tracing of pretreatment (black) and posttreatment (red) cephalograms: A, On the
sella-nasion plane at sella; B, On the palatal plane (PP) at ANS; C, On the mandibular plane at menton;
D, On the PP: Intrusion of the molars and incisors are indicated by changes of the distance from the
mesial buccal cusp to the PP, and from the incisal edge to the PP, respectively. Blue, pretreatment;
Green, posttreatment.

A rigid TPA, shown to be effective against rota-
tional, transverse, and vertical movements of the an-
chor teeth,37,38 was set on the maxillary first molars
to counteract buccal tipping of the posterior segment
and stabilize the transverse width (Fig 13, B).
Compared with high-pull headgear treatment, J-hook
treatment, and other removable techniques for vertical
control, our design required little patient compliance.39
In addition, compared with bulky skeletal anchorage
systems, it significantly simplified the entire force sys-
tem, minimized invasive injury, controlled cost, and
avoided repetitive irritation because of implant
looseness.11
The amounts of intrusion in the anterior and the pos-
terior regions of this patient were satisfyingly compara-
ble to those treated with multiple miniscrews.7,10
Nevertheless, the downside of our approach with TPA
is that it could pose a risk of soft-tissue irritation during
the posterior intrusion; thus, the condition of the pa-
tient’s soft tissue was attentively examined during every
revisit. Furthermore, the TPA loop was set quite distant
from the palatal mucosa to facilitate intrusion through
tongue pressure during swallowing17,18; therefore, in-
quiries were made to ensure her speech, mastication,
or deglutition were not affected. In addition, because
the TPA was placed on the first molars, there could be

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788 Wang et al

Fig 10. Eighteen-month postretention facial and intraoral photographs.

a chance for buccal flaring of the second molars during
the intrusion. Distally elongated hooks soldered on the
palatal side of the bands, which were not included in
this patient, may also be designed in future practice to
preferentially prevent the second molar buccal flaring
by applying forces from the lingual side.
It is fundamental to establish an optimal interincisal
angle by obtaining adequate maxillary and mandibular
incisors torque, which is crucial in the long-term stability
of deep overbite correction.23 When applying the trac-
tion force from the posterior TSADs, a moment in which
the incisors would tip lingually could also be created
because the force vector passed below the center of
resistance of the anterior teeth. Therefore, long traction
hooks were set on the maxillary archwire to get the cen-
ter of rotation as close to the center of resistance as
possible and thus achieve controlled retraction, ideally
bodily movement, of the anterior teeth (Fig 13, A). In
addition, a compensatory and reverse curves of Spee in
the maxillary and mandibular archwire were applied to
prevent incisor lingual inclination and canine distal
tipping. In a word, the resultant forces applied in the
maxillary dentition by combined use of the curved arch-
wire, posterior TSADs, and long traction hooks led to the
controlled retraction of the anterior teeth with
maximum anchorage and the intrusion of the entire
maxillary arch. However, it is also indispensable to
realize that the basic dental and facial morphologic
structures and the response to treatment vary among pa-
tients, and there is still a lack of evidence of anatomic
changes or adaptions in different types of patients after
such treatment, and further explorations are needed.

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Wang et al
Fig 11. Postretention radiographs: A, Lateral cephalogram; B, Superimposed tracing of posttreatment
(red) and postretention (green) cephalograms; C, Panoramic radiograph.
After the treatment, an optimal occlusion with
appropriate overjet and overbite and a stable mandible
position was achieved. Specifically, the condition of
her TMJ was stable, as indicated by cortical continuity
of the condyles and the proper position in the glenoid
fossae (Fig 8, D). Special attention was paid to the incli-
nation of her occlusal planes on account that the steep
anterior occlusal plane and the posterior occlusal plane
can limit the functional mandibular movements and
lead to an overload of the TMJ and constant hyperactiv-
ity of the corresponding muscles, thereby posing a great
risk of TMJ dislocation and disorder,40 especially in skel-
etal Class II malocclusion.41 Tooth movement of this pa-
tient was well controlled from sagittal, transverse, and
vertical dimensions, and a flatter occlusal plane was ac-
quired (SN-AOP from 32.2 to 31.6 , SN-POP from 38.9
to 33.2 ), which helps to normalize the position and
facilitate the stability of the condyle.
Based on a targeted and efficient mechanical design,
we obtained a well-aligned dentition, a stable mandib-
ular position, an attractive smile, and a harmonious
American Journal of Orthodontics and Dentofacial Orthopedics
789
facial profile using minimal invasive TSADs, formed
archwires, and a conventional appliance. The functional
occlusion, as well as the facial and smile esthetics, re-
mained stable during the 18-month retention.
CONCLUSIONS
In this patient with a skeletal Class II hyperdivergent
pattern and VME, total intrusion of the maxillary denti-
tion was achieved to correct the gingival smile and
obtain mandibular counterclockwise rotation. The TMJ
condition and mandibular position were considered dur-
ing the diagnosis, treatment design, and treatment
progress. The treatment plan involved an effective me-
chanical design targeted at maxillary total intrusion
through posterior buccal TSADs, a TPA, and formed
archwires. The biomechanics were theoretically simple
and feasible but rarely used in clinical practice. This
treatment regimen has low technical sensitivity, wide
applicability, high repeatability, and high cost-
effectiveness because of minimal invasive TSADs and
reliable conventional devices. With this case report, we
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790 Wang et al

Fig 12. Smiling photographs: A, Pretreatment photographs (taken right after bracket bonding);
B, Posttreatment photographs; C, Postretention photographs.

hope to inspire a novel camouflage treatment option for
patients with skeletal Class II malocclusion and gummy
smile.
AUTHOR CREDIT STATEMENT
Peiqi Wang contributed to study design, data collec-
tion, data analysis, original manuscript preparation, and
manuscript review and editing; Jiajun Chen contributed
to data collection and data analysis; Xinghai Wang and
Ding Bai contributed to data collection, data analysis,
original manuscript preparation, and manuscript review
and editing; and Yongwen Guo contributed to study
design, data collection, data analysis, original manu-
script preparation, and manuscript review and editing.

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Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Wang et al
Fig 13. Mechanical analysis: A, The compensatory
curve in the archwire provides an intrusive force (Fi) for
the anterior teeth and the far end of the arch, whereas it
exerts an extrusive force (Fe) on the middle part of the
arch that can be counteracted by the miniscrew-applied
intrusive force (FI). The traction force (F) occlusal to the
center of resistance of the anterior teeth (RA) increased
the risk of lingual tipping of the anterior teeth, whereas
the long traction hooks and labial torque in the anterior
archwire (Mlab) helped to prevent lingual tipping of the
maxillary anterior teeth; B, A rigid TPA counteracts with
the buccal tipping moment (M) induced by intrusive force
which is buccal to the center of resistance of the posterior
teeth and can stabilize the arch width. Red, center of
resistance.
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