Orthotown September 2020 - 46

Treating gummy smiles
Fig. 4

One of the most common uses for TADs in our practice is to
correct gummy smiles. This includes cases with absolute, posterior
or anterior maxillary excess. All are treated using TADs as direct
anchorage for intrusion; they vary only in location of intrusion.

Fig. 5

EXAMPLE 1: ANTERIOR GUMMY SMILE
An anterior gummy smile is one in which a patient shows excess
gingival display from upper cuspid to cuspid (Fig. 4). This is taking
into account ideal crown shape and size, where the patient has true
anterior maxillary excess and is not just in need of a gingivectomy or
crown-lengthening procedure. Because there exists some variation
in the patient smile and the patient's willingness or ability to show
a genuine smile, a gummy smile can be best diagnosed through
evaluation of the upper central incisor at rest. We can capture this
by asking the patient to say the word "Emma." If the patient shows
more than 75% of the upper incisor at rest, this is a good indication
that the patient is in need of gummy smile treatment. (Fig. 5).
These cases are treated by placing 1.6-by-6mm TADs between
the upper 2/3s. If slight posterior impaction is desired, bite turbos
with triad gel can be placed on the lower 7s to be squeezed 60
times, six times per day, to impact posterior molars by engaging
the posterior fibers of the temporals.
TADs are placed at the second visit, tied from the anchor to a
14x25 copper nickel titanium (CuNiTi) arch wire with an elastic
(surgical) thread (Figs. 6 and 7). Once the patient has progressed
to larger CuNiTi wires or stainless steel, TADs can be tied to the
wire using power chain looped to the wire or NiTi closing springs
(Fig. 8), depending on the thickness of the tissue.
Once the intrusion is completed, tie the TADs to the wire and
use vertical elastics to close the bite without relapse of the intrusion.
If buccal crown tip is visible because of the moment created by the
intrusion, use a power chain torquing sling to encourage lingual
crown tipping and to prevent flaring of the incisors (Fig. 9).
After the case is completed and the brackets have been removed,
perform a gingivectomy to idealize the tissue shape (Figs. 10 and
11) and make final contours to the hard tissue.

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

EXAMPLE 2: POSTERIOR GUMMY SMILE
A posterior gummy smile is one in which there is a posterior
maxillary excess and a patient displays more than 4mm of posterior
gum (Figs. 14 and 15).
For these cases, 1.6-by-8mm TADs are placed between the upper
5/6s or the upper 4/5s. Bite turbos are placed on the lower 6s with
triad gel to allow the lingual cusps of the upper molars to occlude
with the lower posteriors, to prevent buccal flaring of posterior teeth.
The same protocol as the previous example is used, with TADs
are placed at the second visit and tied to 14x25 CuNiTi arch wire
using elastic thread (Figs. 16 and 17). Once the patient is in larger
CuNiTi or stainless steel wires, the TADs are tied to the wire using
power chain or NiTi closing springs (Figs. 18 and 19).

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Fig. 12: Before

Fig. 13: After

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Orthotown September 2020

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