IJOI 47 iAOI CASE REPORT

Simplified Mechanics for

Gummy Smile Correction

Abstract
This case report describes the interdisciplinary treatment of a 25-year-old woman presenting with chief complaints of bimaxillary
protrusion and excessive gingival display (“gummy smile”). She was dissatisfled with her previous non-extraction orthodontic
treatment, rendered at age 10. The Discrepancy index (DI) for this severe malocclusion was 21. Orthodontic treatment involved
extraction of four premolars to correct protrusion, and skeletal anchorage via four miniscrews (2 anterior and 2 posterior) to intrude
the entire maxillary arch. Space closure utilizing maxillary extra-alveolar (E-A) bone screws reduced lip protrusion and the anterior
miniscrews were used to intrude the maxillary incisors. Following orthodontics, surgical crown lengthening was performed in the
maxillary anterior segment. 32 months of interdisciplinary treatment resulted in a near ideal result as evidenced by a Cast-Radiograph
Score (CRE) of 15 and Pink & White (dental esthetic) score of 3. (Int I Ortho Implantol 2017;47:72-91)

Key words:
Class I malocclusion, bimaxillary protrusion, surgical crown lengthening, self-ligating appliance, gummy smile

History and Etiology Diagnosis

SNA 78º, SNB 75º,

ANB 3º
SN-MP 41º, FMA
Fig. 1 32º

Figs. 2
and 3

5mm

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 Simplified Gummy Smile Correction IJOI 47

Associate editor, Beethoven Orthodontic Course (Left)

Board eligible, Beethoven Orthodontic Course (Center Left)

Founder and president, Beethoven Orthodontic Center, Hsinchu, Taiwan

Publisher, International Journal of Orthodontics & Implantology (Center Right)

Editor-in-chief, International Journal of Orthodontics & Implantology (Right)

Fig. 1: Pre-treatment facial photographs Fig. 4: Post-treatment facial photographs

Fig. 2: Pre-treatment intraoral photographs Fig. 5: Post-treatment intraoral photographs

Fig. 3: Pre-treatment study models (casts) Fig. 6: Post-treatment study models (casts)

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IJOI 47 iAOI CASE REPORT

Fig. 7: Fig. 8:
Pre-treatment lateral cephlometric and panoramic Post-treatment lateral cephlometric and panoramic
radiographs reveal root canal treatment in tooth #13. radiographs document the orthodontic result.
Bimaxillary protrusion and lip strain on closure is noted in
the cephalometric view.

Fig. 9: Superimposed on the anterior cranial base, maxilla and mandible.

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 Simplified Gummy Smile Correction IJOI 47

CEPHALOMETRIC all three planes

SKELETAL ANALYSIS Maintain
PRE-Tx POST-Tx DIFF. Decrease the vertical dimension of the
SNA° (82º)
occlusion (VDO)
SNB° (80º)
Maintain
ANB° (2º)
SN-MP° (32º)
FMA° (25º)
Retract incisors
DENTAL ANALYSIS
Intrude the entire maxillary dentition,
U1 To NA mm (4 mm)
particularly the incisors
U1 TO SN° (104º)
L1 To NB mm (4 mm) Modest increase
L1 TO MP° (90º) to articulate with the lower arch
FACIAL ANALYSIS
E-LINE UL (2-3 mm)
E-LINE LL (1-2 mm) Retract the mandibular incisors
Maintain
Modest increase
as buccal segments are uprighted

Treatment Plan
teeth #5,
ABO 13, 21 and 28
DI Ormco, Glendora, CA

OBS Newton’s A, Ltd., Hsinchu,

Taiwan
Specific Objectives of Treatment IZC

all three planes

Retract
Intrude
Maintain

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IJOI 47 iAOI CASE REPORT

Appliances and Treatment Progress

Fig. 0M
10
Fig. 10:
Fig. 11 The maxillary right first (#5) and left second (#13) premolars
were extracted and high torque brackets were bonded on
the incisors.

Ormco 1/4-in 3.5-oz, Fox

1M
Fig. 12 Fig. 11:
The lower arch was bonded one month after the upper arch.
Standard torque brackets were used on all teeth. Note that
both first premolars were extracted.

Figs. 13-15
TAD

16M
3.5-
Fig. 12:
oz Inter-radicular OBSs were inserted between the central
and lateral incisors, and E-A OBSs were inserted in the
zygomatic crests. Incisor intrusion was accomplished with
Fig. 16 elastomer chains.

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 Simplified Gummy Smile Correction IJOI 47

a
16M

b 23M

c 27M

Fig. 13: Diagrams and corresponding photographs illustrate the mechanics employed at progressive stages of treatment:
a. At 16 months the occlusal plane was gradually steepening.
b. At 23 months anterior bite turbos were bonded on the palatal surfaces of the maxillary central incisors.
c. In the 27th month, retraction force from the IZC miniscrews closes upper space but also provides lingual crown torque to the
upper incisors.

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IJOI 47 iAOI CASE REPORT

0.019x0.025-in SS Figs. 17-19

Fig.
14

Retention

1/4-in 3.5-oz
Fig. 20

Fig. 14:
As extraction space was closed, the right buccal segment
tended toward crossbite, so the archwire was expanded.

Fig. 15:
The force systems provided by the four OBSs and their overall effect on the maxillary arch are complex. The yellow arrow
on the left indicates the intrusive force applied to the incisors. The large red arrow is the retraction force anchored by the
IZC OBS. The small red arrow is the intrusive component on the posterior maxillary segment. The large blue arrow is the net
resultant force on the maxilla, and the blue circular arrow represents the moment of the retraction force around the center of
resistance of the maxilla (red dot with a cross).

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 Simplified Gummy Smile Correction IJOI 47

16M Surgical crown lengthening process

23M Figs. 17b, c and 19

CEJ

Fig. 17d

Fig. 16:
The distance of 3mm between the screws and main arch
wire from 16th to 23rd month have been reduced.

a b c

d e f

Fig. 17:
The surgical crown lengthening procedure for short clinical crowns (a) begins with bone sounding (b) relative to the attached
gingiva (c). The width of the attached gingiva is mapped with a dotted line (d). The gingivectomy is performed with a No. 15
blade (e) and the increased crown exposure (f) is assessed relative to the width of the remaining attached gingiva.

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Fig. 17 Fig. 18

CEJ b
to alveolar crest

#
Fig. 18a

c
Fig. 18c

Final Evaluation of Treatment

CRE

Fig. 18:
Green lines represent the CEJs and black lines are the
alveolar bone level before osteoplasty (a). The white arrow
(a) shows that the biologic width of #10 was only ~1mm (b).
After osteoplasty (b) the biologic width was corrected to
2.5mm, and the gingiva was sutured with #4 Gore-Tex® (Gore
Medical Products, Flagstaff, AZ).

gingival aspects dental aspects

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Fig. 20

HUL

Fig. 19:
The dentogingival complex can be measured by bone
sounding with a periodontal probe. The dimensions of
the normal dento-gingival complex are approximately
3.0mm buccally and lingually, with a mean of 4.5 to 5.0mm
interproximally.3

Fig. 9

Fig. 4

Discussion

gummy smile,

Fig. 20:
Ideal lip length in young adult females is from 20 to 22mm,
whereas it is from 22 to 24mm in young adult males.6

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IJOI 47 iAOI CASE REPORT

ADE

Fig. 21a

passive eruption

VME

2000

Fig. 21: Occlusal plane canting in the sagittal plane:

a. In anterior dentoalveolar extrusion (ADE), only the
anterior portion of the occlusal plane is canted inferiorly.
b. Vertical maxillary excess (VME) involves inferior
positioning of both the anterior and posterior segments
with a flat but often steep occlusal plane.
c. Anterior and posterior maxillary height are measured
cephalometrically as shown.

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 Simplified Gummy Smile Correction IJOI 47

Allergan Inc. Irvine, CA

1968

1976
e.g. phenytoin, cyclosporine, calcium
channel blockers etc

MGJ

Fig. 22

soft tissue

Type I, A Type I, B Type II, A Type II, B

Gingivectomy O O X X

Osteoplasty X O X O

APF X X O O

Fig. 22:
Classification of altered passive eruption is important for determining the most appropriate surgical procedure(s) to correct it.

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IJOI 47 iAOI CASE REPORT

Figs. 23 and 24

Fig. 21a

Fig. 21b

~11mm

Fig. 23:
The decision tree is a flow chart for assessing excessive gingival display to determine the most appropriate clinical
management for a specific problem. The five determinants for decision making are: extent of the excessive gingival display,
clinical crown length, incisal wear, incisor exposure at rest, and the crown-root ratio.

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 Simplified Gummy Smile Correction IJOI 47

a b c

Fig. 24: Smile type is classified as follows:

a. Commissure smile is a Cupid’s Bow configuration that is seen in ~67% of the population. The corners of the mouth are
elevated and projected anteriorly by the levator muscles of the upper lip. The teeth are exposed in a smile arc with a base at
the incisal edge of the maxillary central incisor.
b. Cuspid smile is seen in ~31% of the population. The shape of the lips is commonly visualized as a diamond. The levator labii
superior muscles contract first, exposing the maxillary cuspids, then the corners of the mouth contract projecting the lips
upward and outward.
c. Complex smile is seen in ~2% of the population. The shape of the lips are typically illustrated as two approximating
chevrons. The levators of the upper lip and corners of the mouth contract simultaneously with the depressors of the lower
lip, to expose all the upper and lower teeth.

a b c

Fig. 25: Smile line is classified as follows:

a. Low smile line, exposing less than 75% of the maxillary incisors and no gingiva, is seen in 20.48% of the population.
b. Average smile line, exposing 75-100% of the maxillary anterior teeth along with interproximal gingiva, is seen in 68.94% of
the population.
c. High smile line, exposing 100% of the anterior segment along with a contiguous band of gingiva., is seen in 10.57% of the
population.

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IJOI 47 iAOI CASE REPORT

Fig. 23

Fig. 25
Figs. 22 and 23 Fig. 23

Fig. 26:
Pre- and post-treatment images of the current patient’s smile. The gummy smile has been improved remarkably by
orthodontics and surgical crown lengthening.

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Fig. 27:
Superimposed on the anterior cranial base, maxilla and mandible. The upper and lower dentition remain stable. No relapse
was noted.

Conclusion

Fig. 26

Fig. 27 Acknowledgment

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IJOI 47 iAOI CASE REPORT

References
1. Lang NP, Löe H. The relationship between the width 12. Po l o M . B o tu l i nu m t ox i n ty p e A (B o t ox ® ) f o r th e
of keratinized gingiva and gingival health. Journal of neuromuscular correction of excessive gingival display on
Periodontology 1972;43:623-627. smiling (gummy smile). Am J Orthod Dentofacial Orthop
2. Yeh HY, Chang CH. Robert WE. Implant-orthodontic 2008;133:195-203.6
combined treatment for gummy smile with multiple missing 13. Newman MG, Takei HH, Carranza FA. Carranza’s Clinical
teeth. Int J Ortho Implantol 2013;32:16-32. Periodontology. 9th ed. Saunders; 2002. p. 31.
3. Kois J. Altering gingival levels. The restorative connection. 14. Cohen E. Atlas of cosmetic and reconstructive periodontal
1.Biologic variables. J Esthet Dent 1994;6:3-9. surgery. 3rd ed. BC: Decker; 2007. p. 259.
4. Hulsey CM. An esthetic evaluation of lip-teeth relationships 15. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS.
present in the smile. Am J Orthod Dentofac Orthop 1970; New approach to the gummy smile. Plast Reconstr Surg
57:132-144. 1999;104:1143-1150. Discussion 51-2.
5. Chen CK. Diagnosis and therapy of gummy smile. Beethoven 16. Philips E. The classification of smile patterns. J Can Dent Assoc
Podcast Encyclopedia in Implant Forum No.38. Hsinchu: 1999;65:252-254.
Newton’s A Ltd; 2013.6. 17. Tjan A, Miller G. Tjan AHL, Miller GD. Some esthetic factors
6. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod in a smile. J Prosthet Dent 1984;51:24-28.
1992;62:91-100. Discussion 1-2. 18. Peck S. Peck L, Kataja M. Some vertical lineaments of lip
7. Wu H, Lin J, Zhou L, Bai D. Classification and craniofacial position. Am J Orthod Dentofacial Orthop 1992;101:516-524.
features of gummy smile in adolescents. J Craniofac Surg 19. Kaya B, Vyar R . Influence on smile attractiveness of the
2010;21:1474-1479. smile arc in conjunction with gingival display. Am J Orthod
8. Fushima K, Kitamura Y, Mita H, Sato S, Suzuki Y, Kim YH. Dentofacial Orthop 2013;144(4):541-547.
Significance of the cant of the posterior occlusal plane in class 20. Vig RG, Brundo GC. The kinetics of anterior tooth display. J
II division 1 malocclusions. Eur J Orthod 1996;18:27-40. Prosthet Dent 1978;39:502-504.
9. Janson GR, Metaxas A, Woodside DG. Variation in maxillary 21. Darwin C. The expression of the emotions in man and animal.
and mandibular molar and incisor vertical dimension in Chapter 14. London: John Murray; 1872. p. 347-366.
12-year-old subjects with excess, normal, and short lower
anterior face height. Am J Orthod Dentofacial Orthop
1994;106:409-18.
10. Garber DA, Salama MA. The aesthetic smile: diagnosis and
treatment. Periodontol 2000 1996;11:18-28.
11. Simon Z, Rosenblatt A, Dorfman W. Eliminating a gummy
smile with surgical lip repositioning. Journal of Cosmetic
Dentistry 2007;23:100-108.

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 Simplified Gummy Smile Correction IJOI 47

LINGUAL POSTERIOR X-BITE

Discrepancy Index Worksheet 1 pt. per tooth Total = 0

BUCCAL POSTERIOR X-BITE
TOTAL D.I. SCORE 21 2 pts. per tooth Total = 0
OVERJET
CEPHALOMETRICS (See Instructions)
0 mm. (edge-to-edge) = 1 pt.
1 – 3 mm. = 0 pts. ANB ≥ 6° or ≤ -2° = 4 pts.
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 3 pts.
Each degree < -2° x 1 pt. =
7.1 – 9 mm. = 4 pts.
> 9 mm. = 5 pts.
Each degree > 6° x 1 pt. =
Negative OJ (x-bite) 1 pt. per mm. per tooth =
SN-MP
T
Total = 2 ≥ 38° = 2 pts.
Each degree > 38° x 2 pts. =
OVERBITE
≤ 26° = 1 pt.
0 – 3 mm. = 0 pts.
3.1 – 5 mm. = 2 pts. Each degree < 26° x 1 pt. =
5.1 – 7 mm. = 3 pts.
Impinging (100%) = 5 pts. 1 to MP ≥ 99° = 1 pt.

T
Total = 2 Each degree > 99° x 1 pt. =

Total = 2
ANTERIOR OPEN BITE
0 mm. (edge-to-edge), 1 pt. per tooth OTHER (See Instructions)

then 1 pt. per additional full mm. per tooth Supernumerary teeth x 1 pt. =
Ankylosis of perm. teeth x 2 pts. =
T
Total = 0 Anomalous morphology x 2 pts. =
Impaction (except 3rd molars) x 2 pts. =
Midline discrepancy (≥3mm) @ 2 pts. =
LATERAL OPEN BITE Missing teeth (except 3rd molars) x 1 pts. =
Missing teeth, congenital x 2 pts. =
2 pts. per mm. per tooth Spacing (4 or more, per arch) x 2 pts. =
Spacing (Mx cent. diastema ≥ 2mm) @ 2 pts. =
T
Total = 0 Tooth transposition x 2 pts. =
@ 3 pts. =
3 6
Skeletal asymmetry (nonsurgical tx)
CROWDING (only one arch) Addl. treatment complexities x 2 pts. =

1 – 3 mm. = 1 pt. Identify: Severe gummy smile and bimaxillary protrusion

3.1 – 5 mm. = 2 pts.
5.1 – 7 mm.
> 7 mm.
=
=
4 pts.
7 pts.
Total = 6
IMPLANT SITE
Total
T = 7
OCCLUSION

2
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side pts.
Full Class II or III = 4 pts. per side pts.
Beyond Class II or III = 1 pt. per mm. pts.
additional

Total = 2

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IJOI 47 iAOI CASE REPORT

Occlusal Contacts

Cast-Radiograph Evaluation 5

Total Score:
15
Alignment/Rotations

4 1 1 1 1
1
1

1 1

Marginal Ridges

1 Occlusal Relationships
11

Interproximal Contacts
Buccolingual Inclination
1
1 1

Overjet Root Angulation

0 3
1 1

1
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.

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 Simplified Gummy Smile Correction IJOI 47

IBOI Pink & White Esthetic Score (Before Surgical Crown Lengthening)
Total Score: = 7
1. Pink Esthetic Score
Total =
4
1. M & D Papillae 0 1 2
5
555 4
444
6 2. Keratinized Gingiva 0 1 2
6626 3
33355
222 55 14
11414 3. Curvature of Gingival Margin 0 1 2
3 4
2
222 333 1
111 4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

""" 1. M & D Papilla

2. Keratinized Gingiva
0 1 2

0 1 2

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score ( for Micro-esthetics ) Total = 3

1. Midline 0 1 2

2. Incisor Curve 0 1 2
1
4 3
444 333 111 3. Axial Inclination (5°, 8°, 10°) 0 1 2
2
1
111 222 4. Contact Area (50%, 40%, 30%) 0 1 2
3
4
444 333 5
555 6
666 5. Tooth Proportion (1:0.8) 0 1 2
2
222 6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

4. Contact Area (50%, 40%, 30%) 0 1 2

5555
5. Tooth Proportion (1:0.8) 0 1 2

6. Tooth to Tooth Proportion 0 1 2

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