Correction of a severe gummy smile without surgery

The use of mini screws as temporary anchorage devices has revolutionized orthodontics. The following case illustrates a type of orthodontic correction which was impossible to consider without surgery just a few years ago.

Case history :

This 25 year old woman had started an orthodontic treatment 2 years earlier before being to Dr. John Graham orthodontist, practicing in Litchfield Park, Arizona.
One of the patient’s chief complaint was that she didn’t like her gummy smile. The first series of photographs shows the severity of that gummy smile; more than 1 cm (10 mm) of gingiva is visible upon smiling.
The initial treatment plan included a “maxillary impaction” which is an orthognathic surgery procedure aimed at “moving up” the upper jaw to reduce the gummy smile.
Having lost her insurance coverage, the patient could no longer afford the surgical fee so the initial treatment plan had o be modified. Dr Graham offered to use temporary anchorage devices (TADs) to intrude the maxillary dentition and correct the gummy smile.
The photos (A, B, C) below show the patient as she was transferred to Dr. Graham. (D) At the end of treatment, after the use of TAD mini-screws and reduction of the gummy smile.

Sourire gingival de 10 mm diminué par ingression ou intrusion orthodontique avec mini-vis d’ancrage.

10 mm gummy smile decreased by orthodontic intrusion with mini-screw anchorage (TADs). (A, B, C) Occlusion when the case was transfered to Dr. Graham.. (D) At the end of treatment, after the use of mini-screws to reduce the gummy smile.

Although the occlusion and tooth alignment were acceptable at this stage of treatment (transfer), the smile still showed a lot of gingiva because this correction was originally planned to been done surgically. Treatment goals were still aimed at reducing the excessive gummy smile.

Intrusion orthodontique pour un sourire gingival, Cas traité par John Graham, Phoenix, AZ

Acceptable occlusion prior to orthodontic intrusion using mini-screws.

Orthodontic mechanics used for the intrusion of the maxillary dentition

Mécanique orthodontique utilisée pour faire l'ingression du maxillaire supérieur

4 mini screws provided the necessary anchorage for the intrusion mechanics aimed at intruding the upper dentition and reducing the “gumminess” of the smile.

Cone Beam Computer Tomography (CBCT) imaging

Tomodensitométrie volumique à faisceau conique (TVFC) montrant la position de mini-vis d’ancrage utilisées pour l'ingression orthodontique d'un sourire gingival. Cas traité par John Graham, Phoenix, AZl.

Images from a Cone Beam Computer Tomography (CBCT) showing the position of the mini-screws (arrows). (A) Views of right, center and left sides. (B) Occlusal view showing the mini-screws positioned between the roots.

Cone Beam Computer Tomography (CBCT). Initial and final stages.

tomodensitométrie volumique à faisceau conique (TVFC) CBCT montrant le résultat de l'ingressionorthodontique à l'aide de mini-vis d’ancrage. Cas traité par John Graham, Phoenix, AZ

Vertical changes in the position of the teeth visible as shown in a 3D scan (Cone Beam Computer Tomography (CBCT)) before and after the intrusion.

To learn more about Cone Beam Computer Tomography imaging (CBCT)

Final results

Correction d'un sourire gingival sévère en orthodontie avec des mini-vis d’ancrage temporaires.

(A) Final profile. (B) Front view and (C) smiling after orthodontics. The gummy smile is gone, no surgery!

Occlusion suite à la correction d'un sourire gingival (gummy) à l'aide de mini-vis d’ancrage TADs. Dr John Graham orthodontist

Final occlusion

Correction d'un sourire gingival en orthodontie. Dr John Graham.

(A) Teeth during treatment, (B) at the end of treatment and (C) after the gingiva has been laser reshaped to give it a better contour. A dental facette was made by the general dentist on the upper right central incisor.

To learn more about soft tissue laser and how it can be used to modify gingival contour and improve esthetics.

Correction d'un sourire gingival en orthodontie par Dr John Graham

(A) Severe gummy smile showing 1 cm of gingiva before treatment. (B) At the end of treatment. (C) After the installation of a dental facette on a central incisor. Note that a surgical procedure was done to modify the chin (genioplasty).

To learn more about genioplasties

Thanks to Dr. John Graham for sharing this case.

Poser une question ou laisser un commentaire (40)

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rabih sarkis says:

2014/04/18 at 16 h 34 min

durant la premiere photo la musculature est assez tendue ,alors que ds la 2eme photos la musculature est tres relachee le bord incisale est toujours a sa place

Dr Jules says:

2014/04/18 at 17 h 08 min

C’est ce qui semble être le cas mais le fait d’avoir “impacté” le maxillaire de près de 10 mm aide beaucoup au relâchement de la lèvre supérieure au repos. Les photos ont été prises en demandant simplement à la patiente de sourire dans les 2 cas. Peu importe que la musculature semble tendue ou pas, la distance entre le nez et la lèvre supérieure est approximativement la même avant et après l’impaction maxillaire, ce qui confirme une impaction “squelettique”. Ceci cause aussi une auto-rotation mandibulaire anti-horaire qui permet une meilleure compétence labiale sans que la patiente ait à “forcer” la musculature péri-orale, ce qui donne l’air plus crispé sur la photo “avant”.

Reply
dr nidhal says:

2017/01/11 at 2 h 57 min

Oui c vrai. Et c normal d’après moi. Car une impaction de 10mm!!! Fallait voir l’état des racines… Il faut distinguer ce qui est realisable orthodontiquement de ce qui est de l’ordre de la chirurgie. Et oui le botox aide aussi

Reply
1. Dr Jules says:
  
  2017/01/13 at 8 h 03 min
  
  Vrai aussi mais dans le cas des impactions maxillaires, les “règles de l’art” viennent de changer complètement avec l’avènement des mini-vis d’ancrage. Plusieurs cas traités jadis avec des impactions maxillaires chirurgicales peuvent l’être avec les mini-vis d’ancrage.
  
  Un grand chirurgien maxillo-facial américain de renom a même mentionné que de tels protocoles rendraient éventuellement l’impaction maxillaire chirurgicale inutile (Je ne me souviens plus si c’est Epker ou White qui a fait une telle déclaration).
  
  Reply

Patry Parada says:

2014/11/25 at 9 h 19 min

Excelente e impecable!! felicitaciones

Dr Jules says:

2014/11/29 at 19 h 07 min

Este es de hecho un caso increíble pero todo el crédito debe ir al doctor John Graham que trató a la paciente.

Reply

Manuel Gustavo Chávez Sevillano says:

2014/11/25 at 10 h 42 min

Congratulations for the case! awesome!
Just I want to ask to you for the stability on long- term . Do you have photos of control after one or two year?
Thanks
Manuel Gustavo Chávez Sevillano
D.D.S. Orthodontist

Dr Jules says:

2014/11/29 at 19 h 03 min

Unfortunately, I don’t have any other records about this case. Please see this other answer.

Reply

Dr.Nadeem Ahmed says:

2014/11/25 at 11 h 46 min

sir this is the best non surgical case I have seen so far…just gr8888.

Dr Jules says:

2014/11/26 at 22 h 10 min

I find it impressive too but the credit should go to Dr. John Graham who treated her and who was instrumental in developing this type of temporary anchorage mini-screw and the clinical protocols associated with this technique.

Reply

agnes s. sansolis says:

2014/11/25 at 16 h 29 min

Thanks for sharing this case ,it will be a big help for my daugther in the future taking up Dentistry
.

Dr Jules says:

2014/11/26 at 22 h 11 min

Thanks to Dr. Graham for allowing me to share his work and this excellent case!

Reply

Abdusalam says:

2014/11/25 at 17 h 12 min

very good effort and results but what about stabillity, retention protocol, x- Ray to evaluate root resorption post treatment.

Dr Jules says:

2014/11/29 at 19 h 01 min

As far as I know, this case remained stable and I don’t know if Dr. John Graham (who treated her) has published any follow up records about the case.

You may be interested in the AJODO article quoted in another answer where Drs Sheffler, Proffit ans Phillips looked at the stbility of similar mini-screw intrusion for 33 consecutively treated cases.

Reply

Dr. Emma Eduarte says:

2014/11/26 at 1 h 51 min

How long it takes to treat that severe gummy smile?*

Dr Jules says:

2014/11/26 at 22 h 07 min

This case was treated by Dr. Graham and, if I remember correctly, the “intrusion” part of the treatment was ± 7 months.

Reply
1. dr abdul hafiz says:
  
  2014/11/27 at 8 h 17 min
  
  What about the subsequent autorotation of the mandible as i dont see any existing overjet prior treatment.
  
  Reply
  1. Dr Jules says:
    
    2014/11/29 at 18 h 58 min
    
    I don’t have any photographs or radiographs pre treatment and I am no sure that Dr. Graham (who treated this case) does either as he “inherited” this case as a transfer case in the middle of treatment before doing the intrusion with the TADs but I’ll check with him.
    
    Reply

Rashdan Wasfi M says:

2014/11/27 at 8 h 37 min

I am sure that this is not the screws effect alone she had both crown lengthening and botulinum toxin to paralyze some of upper lip musculature …. we have to remember that it is only a screw and that soft and hard tissues could limite some movements even with the help of the screws

Dr Jules says:

2014/11/29 at 18 h 47 min

Unfortunately, since I didn’t treat this case myself, I don’t have all the details to answer this question but I’ll check with Dr. John Graham. SHe does indeed seem to have longer clinical crowns at the end of treatment so she probably had a gingivectomy done but concerning Botox… I have no idea.
You are right in that bone offers resistance to orthodontic movement but teeth can still be moved long distances when the proper forces are applied. Dr graham used 4 screws in that case so the intrusion forces were distributed fairly evenly around the upper arch.

You may be interested in an article about a similar topic (maxillary intrusion with TADs) in this month’s AJODO (American Journal of Orthodontics and Dentofacial Orthopedics Volume 146, Issue 5, Pages 594–602, November 2014) By Nicole R. Scheffler, William R. Proffitt and Celb Philips entitled “Outcomes and stability in patients with anterior open bite and long anterior face height treated with temporary anchorage devices and a maxillary intrusion splint” in which they looked at 33 consecutive patients who had intrusion of maxillary posterior teeth with a maxillary occlusal splint and nickel-titanium coil springs to temporary anchorage devices in the zygomatic buttress area, buccal and apical to the maxillary molars. The followintg illustration is from that article.

Dr Scheffler also allowed me to use her material to write this section about maxillary intrusion with mini-secrews in open bite cases.

Reply

Rashdan Wasfi M says:

2014/11/30 at 9 h 12 min

Thank you dr. Jules for your reply.
Yes it is an interesting article which used different mechanics … i am doing a research project on botox for GS and one of the most consistent features is ending up with obliteration of nasiolabial fold somewhere along its length after botox injection for gummy smile… which is obvious in your case photoes .

Dr Jules says:

2014/11/30 at 9 h 51 min

Thanks for sharing this Rashdan.
This is a very interesting topic indeed. I am getting more and more questions about treatment with the botulism toxin (Botox), mainly in the French section of the website for smile asymmetries, gummy smiles , TMD, deep labial-mental folds, etc. You are obliviously more knowledgeable than me on that topic as I have never used it myself (dentists can’t use Botox here…). Again, I don’t know if that patient had such a treatment or not as I have not treated her but I’ll inquire.

I am sure that you are aware and probably have access to the few articles discussing this topic in the AJODO.
Do not hesitate to share the conclusions of your work here as more and more poeple, patients and practitioners alike, are looking for information about this topic.

In your experience, how long will the effects of Botox last on the upper lip for reducing a gummy smile? The sources that I red say anything between 5-9 months after which period if “fades” out and must be “redone”

Reply

CICI says:

2014/12/16 at 21 h 14 min

where is this dr. located?

Dr Jules says:

2014/12/16 at 21 h 36 min

Dr. Graham’s orthodontic practice is in Litchfield Park, Arizona and here’s the link to his website.

Reply
1. CICI says:
  
  2014/12/16 at 23 h 06 min
  
  Thank you for your quick reply! Do you know any orthodontist near NJ/NY using the TADs to treat gummy smile like this? I’ve searched a lot but not a lot of orthodontists have the same experience though they use TADs. I think you have more knowledge than me. Could you please recommend some? Thank you so much! Happy holidays!
  
  Reply
  1. Dr Jules says:
    
    2014/12/20 at 19 h 02 min
    
    Unfortunately, I don’t know other orthodontist’s qualifications and interest in using TADs for such cases. You may have to inquire directly to the orthodontists but there are some using this technique in NJ or NY.
    
    Reply

Andres bello says:

2014/12/28 at 12 h 44 min

Why were the brackets changed in this case?
Hello dr Jules, i wondering why dr Graham changes the brackets in the patient. In the first photograph i can see preadjusted brackets (i believe they are sinergy braces) and in the others images i see self ligated braces, so why he decided to do that?
Thanks a lot !

Dr Jules says:

2014/12/28 at 15 h 48 min

You are very observant… and right!
We would need to ask him directly why he changed the brackets but my guess would be that, since I know for a fact that he “inherited” this case as a transfer case, he was more comfortable working with the self-ligating brackets than with the ones the patient was transferred with. This is a matter of personal preference for every orthodontist. In my opinion, the intrusion technique he used with TADs is irrelevant to the type of brackets placed on the teeth and these protocols would have worked similarly if the initial brackets would have been kept.

Reply
1. Priyanka says:
  
  2017/11/10 at 3 h 52 min
  
  I am having orthodontics treatment and i want to know how much time it will take for TAD ??
  
  Reply
  1. Dr Jules says:
    
    2017/11/12 at 11 h 48 min
    
    It all depends what the TAD is used for exactly. Only your orthodontist can answer this question for your specific case.
    
    Reply

Andres bello says:

2014/12/28 at 16 h 46 min

Thank you for your reply, ????
happy holydays dr Jules!

Honey says:

2015/02/05 at 0 h 25 min

Is Dr. Graham treat who already have braces? I am exposing too much gums when I smile and I am newly wearing braces, I truly interested with this treatment. Please help me how to make this treatment happen. Is Dr. Graham accept insurance? If yes, what kind of dental insurance he accepts?
Thank you!

Dr Jules says:

2015/02/06 at 9 h 23 min

You would have to verify all this specifically with him. Here is his website ; litchfieldparkortho.com

The case shown here already had braces put on by another orthodontist when it was transfered to Dr. graham

Reply

goga says:

2015/03/21 at 17 h 28 min

Does anybody know any good ortodontist in Europe expirienced in treating gummy smile with TAD screws? Thanks

goga says:

2015/05/07 at 8 h 24 min

if someone does know some good orthodontist from Europe who had similar results like Dr. Graham, please let me know on e-mail: [email protected]

Reply

miki says:

2015/04/17 at 7 h 17 min

does dr. graham work in phoenix or salt lake city or both? 🙂

Dr Jules says:

2015/04/17 at 7 h 49 min

He seems to workin 2 offices:
– Litchfield Park, Arizona 85340

– Salt Lake City, UT 84105

Reply
Dr Jules says:

2015/04/17 at 7 h 49 min

He seems to work in 2 offices:

– Litchfield Park, Arizona 85340

– Salt Lake City, UT 84105

Reply

Naina says:

2017/07/02 at 8 h 17 min

Hi doc.. Did this process of treatment will no back to normal position? Im afraid after for many year the gummy smile will be back to normal position.. So it is not worth it..

Dr Jules says:

2017/07/03 at 20 h 58 min

It remained stable as far as I know but I didn’t treat this case myself.

Reply

Correction of a severe gummy smile without surgery

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Orthodontic mechanics used for the intrusion of the maxillary dentition

Final results

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