Journal of the World Federation of Orthodontists xxx (2015) 1e6

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Journal of the World Federation of Orthodontists

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Correction of severe deep bite and gummy smile using mini-screw

anchorage: A case report
Pawankumar Dnyandeo Tekale a, *, Ketan K. Vakil b, Murlidhar R. Sastri c,
Jeegar K. Vakil d, Chetan O. Agrawal e, Ketan Ashokrao Gore f, Bhuwan Saklecha g
a
Senior Lecturer, Department of Orthodontics, Dr Rajesh Ramdasji Kambe Dental College and Hospital, Akola, Maharashtra, India
b
Professor and Head, Department of Orthodontics, S.M.B.T. Dental College and Hospital, Sangamner, Maharashtra, India
c
Professor, Department of Orthodontics, S.M.B.T. Dental College and Hospital, Sangamner, Maharashtra, India
d
Senior Lecturer, Department of Orthodontics, S.M.B.T. Dental College and Hospital, Sangamner, Maharashtra, India
e
Orthodontist and Private Practice, Pune, Maharashtra, India
f
Senior Resident, Department of Orthodontics, S.M.B.T. Dental College and Hospital, Sangamner, Maharashtra, India
g
Senior Lecturer, Department of Orthodontics, Index Institute of Dental Science, Indore, Madhya Pradesh, India

a r t i c l e i n f o a b s t r a c t

Article history: The patient was a 23-year-old girl who had an Angle Class II Division 1 malocclusion, severe overjet, and
Received 16 June 2015 deep bite with a gummy smile. She had both impacted mandibular canine teeth. The objectives were to
Received in revised form correct deep bite, gummy smile, accentuated overjet, alignment of impacted canine and to achieve
9 September 2015
adequate overbite and overjet. The treatment involved extraction of maxillary first premolars proceeding
Accepted 14 September 2015
Available online xxx
with retraction and intrusion of the upper anterior teeth with mini-screw implants as the orthodontic
anchorage. After treatment, adequate overbite and overjet and a satisfactory maxillary gingival exposure
in the smile were obtained. The mini-screw implant anchorage method is useful for correction of severe
Keywords:
Deep bite
overjet and a deep bite with a gummy smile.
Gummy smile Ó 2015 World Federation of Orthodontists.
Mini-screw anchorage
Intrusion

1. Introduction gummy smile. Mini-plates and mini-screws are now frequently

An excessive display of gingival tissue on smiling, usually
referred to as a “gummy smile,” is often aesthetically displeasing
[1]. Several etiologic factors have been proposed in the literature;
these include skeletal, unigingival, and muscular factors that may
occur alone or in combination. Gummy smile is an aesthetic prob-
lem for some patients and a frequent finding that can occur as a
result of various intraoral or extraoral etiologies [1e3]. Thus,
concise evaluation of etiology and diagnosis and implementation of
treatment plan had important roles in the treatment outcome. If a
gummy smile is characterized by overgrowth of anterior vertical
maxillary excess, the outcome may not always be successful with
conventional orthodontic therapy alone. In such cases, surgical
therapy, such as that provided by a Le Fort impaction or maxillary
gingivectomies, are often chosen to gain a good smile [3].
However, if the patients are unwilling to undergo surgical
treatment, an alternative method must be considered to treat the
* Corresponding author: Dnyanita Orthodontic Care, Opp District Court, Near
Dunakhe Hospital, Adalat Road, Aurangabad, Maharashtra, India, 431001.
E-mail address: pawan0804@gmail.com (P.D. Tekale).
used for establishing absolute anchorage for orthodontic tooth
movement [4e7]. Surgical invasion is minimal during mini-screw
insertion, compared with that associated with placement of mini-
plates, because mucosa should be cut and a flap is required. In
contrast, the mini-screws provide sufficient anchorage for incisor
retraction in Class II treatment without unwanted orthodontic side
effects. With Class II treatment in premolar extraction cases, it had
been shown that mini-screw anchorage could provide more effec-
tive incisor retraction than the traditional anchorage method in
which a headgear and a transpalatal arch were used [7,8]. In this
case report, we present the management of severe deep bite,
gummy smile, and accentuated overjet for a skeletal Class II patient
using mini-screw anchorage.
2. Etiology and diagnosis
The patient, a 22-year-old girl, had a convex profile, Angle
Class II malocclusion, skeletal Class II base with retruded
mandible. Her chief complaints were forwardly placed upper
front teeth and excessive display of gums while smiling. We had

2212-4438/$ e see front matter Ó 2015 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2015.09.001

Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
2 P.D. Tekale et al. / Journal of the World Federation of Orthodontists xxx (2015) 1e6

previously recommended orthodontic treatment with orthog- 3. Treatment objectives

nathic surgery. However, the patient was not willing to undergo
the surgery. The clinical examination revels that the skeletal Class
II base with prognathic maxilla and retrognatic mandible rela-
tionship, proclined and forwardly placed maxillary anteriors,
increased overjet, deep bite, accentuated deep curve of Spee,
impacted right and left mandibular canines, protrusion of upper
and lower lips, and incompetent lips. The functional examination
reveals incisal and canine guidance without prematurity and
shift. The patient had no temporomandibular joint symptoms. No
deviation and pain during the border movement of the mandible
were discovered. No short or hyperactive upper lip or vertical
maxillary excess was found.
Pretreatment extraoral, intraoral photographs (Fig. 1) and
cephalogram and a panoramic radiograph (Fig. 2) were taken
before treatment. The cephalometric analysis (Table 1) demon-
strated a Class II skeletal relationship (Point A-Nasion-Point B
Angle 5
) as a result of the prognathic maxilla. The A point was
Sella-Nasion-Point A Angle 84
, and B point was Sella-Nasion-Point
B Angle 79
. The angle between the maxillary incisors and the
Sella-Nasion line plane was 118
, and the Incisor mandibular
plane angle was 101
, which indicated that the protrusive
profile was mainly caused by the proclined maxillary anterior
teeth.
The treatment objectives were to create a satisfactory occlusion
with correction of deep bite, accentuated overjet, and gummy smile
and alignment of impacted mandibular canine teeth. Correction of
axial inclination of maxillary and mandibular anteriors with
retraction and intrusion of the maxillary anterior teeth was indi-
cated to reduce deep bite and the convex profile, protruded upper
and lower lip, and incompetent lips.
4. Treatment alternatives
The treatment options were discussed with the patient. The first
option was traditional orthodontic treatment with Le Fort I surgery
to reduce the gingival exposure and to correct maxillary protrusion.
The second option involved orthodontic intrusion of the maxillary
anterior region using mini-screw anchorage. Because the surgical
treatment plan was declined by the patient, the treatment objec-
tives essentially consisted of vertical control and distalization of the
anterior teeth.
The treatment alternatives were presented to the patient.
1. Extract the maxillary first premolars and use Kalra Simultaneous
Intrusion and Retraction arch-wire for simultaneous intrusion

Fig. 1. Showing pretreatment intraoral and extraoral photographs.

Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
 P.D. Tekale et al. / Journal of the World Federation of Orthodontists xxx (2015) 1e6 3

Fig. 2. Pretreatment lateral cephalogram and OPG.

and retraction of maxillary anterior teeth. It requires precise wire After we discussed these alternatives with the patient, she chose
bending and anchorage preparation. the third option.
2. Extract the maxillary first premolars and use J-hook headgear
as anchorage for retraction and intrusion. The disadvantage
was that the effect of this treatment depended on the patient’s 5. Treatment progress
cooperation.
3. Extract the maxillary first premolars and use mini-screws to Orthodontic treatment began in July 2012 and lasted for
provide absolute anchorage for maximum intrusion and 23 months. Preadjusted 0.022 MBT brackets (3M Unitek) were
retraction of the maxillary anterior teeth to correct deep bite, bonded to all teeth. As the treatment progressed, the left mandib-
gummy smile, and overjet. The disadvantage was that the ret- ular canine was surgically removed as prognosis was not good and
ruded mandible would not be corrected. the deciduous canine is kept in place. On right side, the over-
retained deciduous canine was extracted and the impacted right
Table 1
mandibular canine was allowed to erupt.
Cephalometric analysis for case With sequential nickel-titanium archwires, alignment and
leveling were achieved in 2 months. Then, 0.019e0.025 SS wire
Sr. Parameter Mean Pretreatment Posttreatment
No.
was placed in the upper arch with a soldered post on maxillary
archwire between the maxillary lateral incisor and canine teeth.
Skeletal
1 SNA 82 84 82.2 Placement of mini-implant (Dentos, 1312-08) was done in the
2 SNB 80.5 79 80 buccal interradicular space between the maxillary second pre-
3 ANB 2 5 2.5 molar and maxillary first molar (Fig. 3) on right and left side,
4 N perp. to point A 02 1 0 under thorough aseptic conditions using surface anesthetic gel
5 N perp. to point Pog 0 to e4 e2 e4
6 Go-Gn to SN 32 20.5 24
(benzocaine 5% - ultradent products). Lower 0.018 SS wire was
7 J angle 85 88 86 placed with open coil spring to maintain the space to allow the
8 Y axis 66 66 67 mandibular right canine to erupt and align in the arch. After
9 Facial axis angle 0 e2 þ4 1 month, nickel-titanium closed-coil springs were used for
10 Sum of posterior angles 396  6 386 389.5
retraction and intrusion of maxillary anterior teeth. As the treat-
Dental
11 U1 to NA angle 22 37 21 ment progressed, the impacted right mandibular canine was seen
12 U1 to NA 4 15 2 to erupt; sequentially, it was bonded and aligned in the arch with
13 U1 to SN angle 102 118 108 nickel-titanium wires.
14 L1 to NB angle 25 26 32 Further maxillary retraction was achieved with nickel-titanium
15 L1 to A-Pog 1e2 3 1
16 L1 to mand. plane angle 90 101 105
closed coil springs on the temporary anchorage device (TAD). After
17 Interincisal angle 130 113 120 20 months of retraction of the maxillary anterior teeth, both
Soft tissue overbite and overjet were achieved properly with correction of
18 S line to upper lip e2 þ4 e1 gummy smile. In the 20th month of treatment, the first molars
19 S line to lower lip 0 þ2 0
were in a Class II relationship, and her facial profile and smile were
20 Nasolabial angle 90e110 89 100
improved. Posttreatment intraoral and extraoral photographs are
Abbreviations: SNA, Sella-Nasion-Point A Angle; SNB, Sella-Nasion-Point B Angle; shown in Figure 4, and posttreatment lateral cephalogram and
ANB, Point A-Nasion-Point B Angle; N, Nasion; Pog, Pogonion; Go, Gonion; Gn,
Gnathion; SN, Sella-Nasion line; J Angle, Angle of Inclination; Y Axis, Growth Axis
OPG are shown in Figure 5. Figure 6 indicates the superimposition
Nasion-Sella-Gnathion Angle; NA, Nasion-Point A; U1, Upper Incisor; L1, Lower with black color used for pre-treatment and red color for post-
Incisor; A, Point A; S, Steiner Line. treatment.

Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
4 P.D. Tekale et al. / Journal of the World Federation of Orthodontists xxx (2015) 1e6

Fig. 3. Placement of mini-implant in buccal interradicular region.

6. Discussion outcome of the selected treatment, suggested that orthognathic

Gummy smiles can be classified by etiology into soft tissue,
dentoalveolar, and skeletal types. The skeletal type is caused by
excessive vertical maxillary growth and is found in patients with
long-face syndrome. Orthognathic surgery is generally required to
treat this problem [1,3,5]. However, in some dentoalveolar cases,
orthognathic surgery could produce an unfavorable result. For the
patient whose gummy smile is derived from protrusion and
extrusion of the maxillary anterior dentoalveolar complex,
decreased anterior dentoalveolar height after surgery might result
in a low smile [3,9]. These considerations, plus the favorable
surgery was inappropriate for eliminating the gummy smile in our
patient. In addition, the patient thought that improvement of her
profile was not worth the additional cost and risk. As a result,
orthognathic surgery was abandoned after careful consideration.
On the other hand, implants for orthodontic anchorage, such as
mini-plates and mini-screws, have recently been developed. Or-
thodontic treatment with mini-screw anchorage is more comfort-
able for the patient than traditional reinforced anchorage such as
multi-brackets combined with intraoral or extraoral anchorage,
because there is no requirement for the patient’s cooperation.
Nevertheless, the success rate was approximately 80% to 95%, and

Fig. 4. Posttreatment extraoral and intraoral photographs.

Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
 P.D. Tekale et al. / Journal of the World Federation of Orthodontists xxx (2015) 1e6 5

Fig. 5. Posttreatment lateral cephalogram and OPG.

minimum invasion for placement surgery was necessary; the pa-
tients complained of little pain and discomfort after placement of
the mini-screws [4,7e9].
The development of TADs has triggered various novel tech-
niques for treating gummy smiles. Kim et al. [9] introduced a
segmental archwire assisted by placing TADs between the roots of
the maxillary central incisors to correct a gummy smile that was
caused by vertical growth of the maxillary anterior dentoalveolar
complex. Lin et al. [10] and Kim et al. [11] reported on patients with
skeletal gummy smiles treated with a combination of TADs and
periodontal surgery, but there have been no reports of a Class II
Division 1 patient with a gummy smile treated with mini-screws. In
this case, we adopted TADs between the maxillary second pre-
molars and first molars combined with nickel-titanium closed-coil
springs that could provide a continuous total force passing near the
center of resistance of the six anterior teeth [7,8,12]. The force could
be divided into two parts: a greater horizontal force for retraction of
the protrusive anterior dentoalveolar complex and a smaller ver-
tical force for intrusion of the anterior teeth [7,9,12]. To ensure
maximal retraction and prevent excessive lingual tipping of the
anterior teeth, we placed a compensatory curve in the maxillary
archwire, which could counteract the deformation of archwire,
provide torque control on the anterior teeth, and assist in correcting
the deep overbite. Torque control of the anterior teeth also

Fig. 6. Superimposition.

Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
6 P.D. Tekale et al. / Journal of the World Federation of Orthodontists xxx (2015) 1e6
prevented the roots from approximating the cortical plate, which,
when combined with continuous light retraction forces, effectively
reduced root resorption. The treatment with our appliance pro-
duced a satisfactory outcome.
In the present study, mini-screws with a 1.3- or 1.5-mm diameter
were placed at 20
to 30
to the long axis of the proximal tooth. In
previous reports, distances between the mesiodistal central grooves
of proximal teeth were calculated with a panoramic radiograph or
with three-dimensional computed tomography and were defined as
interradicular distances. Therefore, the interradicular distance
might be longer than 3 mm in the buccal root area around screws
that are placed at an oblique angle. Because of the implantation
methods used, the maxillary molars in this study could be moved to
the distal without screw contact with the proximal root. In addition,
there was no root resorption, which is one of the side effects of molar
distal movement that causes great concern.
7. Conclusion
 Retraction and intrusion of maxillary anterior teeth was best
accompanied with mini-screws placed in maxillary buccal
interradicular space between the second premolar and the first
molar.
 Mini-screws placed in the maxillary buccal interradicular space
between the second premolar and the first molar at an oblique
angle were useful for moving maxillary anteriors distally in
nongrowing patients for correction of deep bite and gummy
smile.
Please cite this article in press as: Tekale PD, et al., Correction of severe deep bite and gummy smile using mini-screw anchorage: A case report,
Journal of the World Federation of Orthodontists (2015), http://dx.doi.org/10.1016/j.ejwf.2015.09.001
 The patient’s profile can be improved by correction of overjet
using mini-screws.
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