FOCUS ON: GUMMY SMILE use a transpalatal arch to hold the molars in place while intruding to keep them from rolling out and flaring. However, I like to keep the mechanics simple in these cases and approach it slightly differently. The protocol I use is to place two anterior TADs for intrusion, place bite turbos on the occlusal of the lower 7s, and have the patient do a squeeze exercise that consists of 60 squeezes per day, really concentrating on engaging the posterior fibers of the temporalis muscle to impact the posterior arch, keeping it upright as we intrude the anterior. What I’ve found is that for cases like Brooke’s, where there is 4 mm–6 mm of gum-show, it takes about 10 months of intrusion to get full gummy smile correction. Figure 2 shows Brooke about 4 weeks before I placed the TADs. As you can see, we’ve progressed through our beginning wires to correct rotational and torque issues. At this point, she is in a 16x25 SS wire upper and lower. We will advance to a 19x25 for the majority of intrusion to keep the anterior torques under control while intruding the maxilla. Figure 3 shows Brooke the day we put the TADs in. As you can see, I placed them distal to the 2s and mesial to the 3s. Something to note: It is extremely important not to use too heavy forces. If you do, the upper incisors will flare, and it will be really hard to regain control of the case. There are two ways I attach the TADs to the wire for intrusion force. The first method I use is seen here in Brooke’s case. I took a 5 mm 150g double delta closing spring from the TAD, looped it around the wire, and hooked the other end to the TAD. Using a closing spring is great because the clinician can hook it up once and leave it in for the duration of the intrusion. The only issue with using springs is that it can cause inflammation in the gum tissue and can sometimes embed in the tissue. If that ever happens in a case, I switch to the second method I use, which is power chain. Power chain is great because it’s much lower profile, and clear power chain isn’t nearly as noticeable as the unsightly closing spring. The only downside is that you have to change them out as they lose their elasticity. Figure 4 shows Brooke 3 months into intrusion. Now that the springs have had a chance to start working their magic, the protocol is to start triangle anterior elastics to keep the lower arch coming forward and up to meet the impaction. Brook wore her elastics from the upper post to the lower 3-4 on both sides. 38 Orthodontic practice
Figure 4: 3 months into intrusion
Figure 5: 10 months of intrusion
Figure 5 shows Brooke at 10 months of intrusion. This is about the time when I take a look at the photos to see what’s left of the gummy smile. Keep in mind when evaluating at this point that any patient who is treated like this for a gummy smile will need gingival contouring at the end of treatment. Everyone loses his/her gingival architecture to some degree after impacting the maxilla. At this point, Brooke’s gummy smile is no longer looking gummy! I decided to take the TADs out and work on the finishing touches for her case.
Summary The total treatment time for this case was 22 months. (We spent 10 of those months intruding.) Brooke was hesitant about the idea of TADs, so we started intruding a little
later than usual. If we would have started earlier, I could have finished her a little sooner. Figures 1 and 6 show the before-andafter comparison of Brooke’s case. What a great transformation! Notice how her smile now lights up her face. There are several things I want to point out looking at her before-and-after comparison. In her smiling photographs, notice how her smile doesn’t draw attention to any part of the smile anymore. Before, her smile was dominated by her front teeth. Notice that there is about 1 mm of gum-show from anterior to posterior, which is perfect for a youthful smile. Remember that as women age, the upper lip tends to lengthen so we want to treat for graceful aging as well as beautiful esthetics. Notice how wide and broad her smile is now. The buccal corridors are now Volume 10 Number 2