Journal of the World Federation of Orthodontists 7 (2018) 34e46

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Journal of the World Federation of Orthodontists

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Case Report

Adult gummy smile correction with temporary skeletal

anchorage devices
Satoshi Uzuka a, Jong-Moon Chae b, Kiyoshi Tai c, Takashi Tsuchimochi d,
Jae Hyun Park e, *
a
Associate Professor and Chair, Division of Orthodontics, The Nippon Dental University Hospital, Tokyo, Japan
b
Professor, Department of Orthodontics, School of Dentistry, University of Wonkwang, Wonkwang Dental Research Institute, Iksan, Korea; Visiting
Scholar, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A. T. Still University, Mesa, Arizona
c
Visiting Adjunct Professor, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona, and
Private Practice of Orthodontics, Okayama, Japan
d
Clinical Assistant Professor, Division of Orthodontics, The Nippon Dental University Hospital, Tokyo, Japan
e
Professor and Chair, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A. T. Still University, Mesa, Arizona; International
Scholar, Graduate School of Dentistry, Kyung Hee University, Seoul, Korea

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

Article history: Temporary skeletal anchorage devices were used to correct the gummy smile of a 27-year-old woman.
Received 14 January 2018 She was also missing her maxillary left second molar and mandibular right central incisor. Her
Accepted 28 January 2018 mandibular anterior missing space was closed with orthodontic treatment. Her occlusion, smile es-
thetics, dental midline, and soft tissue profile were significantly improved after her orthodontic treat-
ment. A 2-year follow-up showed that the patient had a stable occlusion and the results of the
Keywords:
orthodontic treatment were maintained.
Temporary skeletal anchorage devices
Ó 2018 World Federation of Orthodontists.
gummy smile
vertical maxillary excess
maxillary intrusion

1. Introduction dentoalveolar extrusion and VME could be effectively corrected

An excessive gingival display on smiling, referred to as “gummy
smile,” “high lip line,” or “high smile line,” is often esthetically un-
pleasant and is undesirable [1,2]. Less than 2 mm of gingival display
is acceptable and is considered youthful, as the amount of exposure
of the maxillary central incisors both at rest and smiling gradually
decreases with age [3]. A gummy smile can be defined as 2.0 mm or
more of maxillary gingival exposure in full smiling. The sexual
dimorphism in smile types indicates that women are twice as likely
as men to have gummy smiles. Although the incidence of excessive
gingival display has not been established, it is common [4,5].
The etiologies of gummy smile include abnormal lip length/ac-
tivity, diminished clinical crown length because of gingival hyper-
plasia or altered passive eruption, dentoalveolar extrusion, and
vertical maxillary excess (VME) [6]. It is necessary to diagnose
the etiologies associated with each individual gummy smile to
prescribe the appropriate treatment modalities. Traditionally,
* Corresponding author. Postgraduate Orthodontic Program, Arizona School of
Dentistry and Oral Health, A. T. Still University, 5835 E. Still Circle, Mesa, AZ 85206.
E-mail address: JPark@atsu.edu (J.H. Park).
only with invasive orthognathic surgery [7,8], but the upsurge of
temporary skeletal anchorage devices (TSADs) in orthodontic
therapy offers an alternative to surgery in some cases. TSADs have
been successfully used for maxillary intrusion, improving gummy
smiles resulting from dentoalveolar extrusion and VME [9e13].
For cases with a multifactorial etiology, a combination of treat-
ment methods should be prescribed to improve each problem. If
possible, overcorrection of one etiological factor can camouflage
another etiological factor that is indirectly or incompletely cor-
rected. This case report details successful correction of a gummy
smile because of VME using TSAD-assisted maxillary intrusion.
Further a 2-year follow-up record of the patient is provided to
establish the stability of the treatment result.
2. Diagnosis and treatment planning
A 27-year-old woman presented with concerns of spacing in
her upper and lower arches at the Division of Orthodontics, The
Nippon Dental University Hospital in Japan. A review of her
medical history, as well as temporomandibular joint evaluation,
showed nothing remarkable. She had a convex profile with

2212-4438/$ e see front matter Ó 2018 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2018.01.004
 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46
Fig. 1. Pretreatment facial and intraoral photographs.
posterior divergence and her smile revealed excessive gingival
show (Fig. 1). Intraoral clinical examination revealed her missing
maxillary left second molar and one mandibular incisor. She had
Class I molar relationship on her right side and Class III molar
relationship on her left side, with bilateral Class I canine re-
lationships. She had an approximately 1 mm overjet and a 50%
overbite. Because of her missing mandibular incisor, her dental
midline was not coincident with her facial midline, and her
maxillary dental midline was deviated by approximately 1 mm to
the right (Figs. 1 and 2).
A panoramic radiograph confirmed that she was missing her
maxillary left second molar and mandibular right central incisor,
and her mandibular left lateral incisor showed short root. It also
showed that her left mandibular third molar was horizontally
impacted along with a difference in the shape of her left and right
condyle. Lateral cephalometric analysis revealed a skeletal Class II
(A point, nasion, B point: 7.8
) relationship with hyperdivergent
growth pattern (sella nasion to mandibular plane: 42.0
). Her
maxillary incisors were retroclined (upper central incisor to sella
nasion line: 87.0
), her mandibular incisors were proclined (incisor
mandibular plane angle: 97.9
), and her lower lip was protrusive
such that it was ahead of the E-line (Fig. 3 and Table 1).
35
3. Treatment objectives
The following treatment objectives were established: (1) cor-
rect VME; (2) correct jaw deformities of the maxilla and the
mandible; (2) coordinate the skeletal and dental midlines; (3)
correct and coordinate the maxillary and mandibular arch forms;
(4) obtain normal overjet and overbite; (5) maintain Class I canine
and establish Class I molar relationships; (6) close the spaces be-
tween her teeth; and (7) improve her gummy smile and facial
esthetics.
4. Treatment alternatives
To improve her gummy smile and facial profile, and to close her
spaces in the dental arches and to attain ideal inclination of
maxillary and mandibular incisors, we recommended orthognathic
surgery, including genioplasty and dental implants to restore her
missing teeth, but she declined the surgical and restorative
treatment options. She wanted to close all the missing spaces
without dental restorations and improve her gummy smile
without surgery. Because of the complexity of the case, TSADs
were chosen to improve her gummy smile and close her missing
36 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46

Fig. 2. Pretreatment dental casts.

spaces, but it would be a challenge to close all her missing areas
and correct her dental midline, so a diagnostic setup model was
fabricated (Fig. 4).
5. Treatment progress
Before the start of orthodontic treatment, the patient was
referred to a general dentist to ensure that she had no active
dental issues that might interfere with treatment. After her dental
clearance, full-fixed 0.022  0.028-inch preadjusted orthodontic
brackets (Clarity ceramic brackets; 3M Unitek, Monrovia, CA) were
placed and bonded on both arches. The wire sizes in both the
upper and lower dental arches were gradually increased from
0.012-inch nickel-titanium (NiTi), 0.016-inch NiTi, to 0.019 
0.025-inch NiTi arch wires over 6 months for leveling and
alignment.
After leveling and alignment, two TSADs (6.0 mm length, 1.6 mm
diameter; Dual Top Auto Screw; Jeil Medical Corp, Seoul, Korea)
were placed in the mesial area of her maxillary lateral incisors along
with a DISCOpender (BioMaterials Korea, Inc., Seoul, South Korea)
and power elastics to provide maxillary anterior intrusion. For
maxillary incisor intrusion, 80 g was used per side [14]. One palatal
TSAD (6.0 mm length, 2.0 mm diameter; BioMaterials Korea, Inc.)
was placed in the para-median area, posteriorly parallel to the
 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46 37

Fig. 3. Pretreatment radiographs: (A) panoramic radiograph; (B) lateral cephalogram; (C) posteroanterior cephalogram.
Table 1
Cephalometric data
palatal roots of her maxillary first molars [15]. For molar intrusion,
Measurement Normal Pretreatment Posttreatment 2-y retention
150 g per side was used [16].
SNA (
) 82.0 78.9 78.5 78.5 On her posterior teeth, the maxillary first molars developed
SNB (
) 80.0 71.1 72.0 71.8
ANB (
) 2.0 7.8 6.5 6.7
slight edge-to-edge bite due to the intrusive force from the palatal
Wits (mm) 1.0 2.2 3.7 3.3 TSAD and transpalatal arch. To correct these side effects while space
SN-MP (
) 32.0 42.0 41.3 41.5 closing, 0.019  0.025-inch stainless steel wire was used to deliver
FH-MP(
) 24.0 30.6 29.9 30.1 buccal crown torque during anterior retraction. It was hoped that
LFH (ANS-Me/ 55.0 61.0 60.6 60.7
this would reduce anterior overjet and increase overbite. On the
N-Me) (%)
U1-SN (
) 104.0 87.0 86.4 86.6 posterior sides, wire was also slightly expanded to correct the edge-
U1-NA (
) 22.0 8.1 7.9 8.1 to-edge bite. Additional torque was not added in the anterior and
IMPA (
) 90.0 97.9 86.2 87.4 posterior portions of the wire to reduce friction during space
L1-NB (
) 25.0 31.1 19.5 20.7 closing. In the mandibular arch, to correct the dental midline as
U1/L1 (
) 131.0 133.1 146.0 144.5
much as possible and to protract the left second molar, one TSAD
U1-NF (mm) 27.5 38.0 32.9 33.8
U6-NF (mm) 23.0 24.7 23.3 24.1 was placed (6.0 mm length, 1.6 mm diameter; Dual Top Auto Screw;
L1-MP (mm) 40.8 45.2 43.8 44.2 Jeil Medical Corp) between her right second premolar and first
L6-MP (mm) 32.1 39.0 39.6 39.5 molar and 0.017  0.025-inch stainless steel wire was used (Figs. 5
Upperlip (mm) 4.0 1.1 2.7 1.8
and 6).
Lowerlip (mm) 2.0 4.5 2.1 0.1
Because the palatal TSAD became lose during treatment, the
ANB, A point, nasion, B point; ANS, anterior nasal spine; FH-MP, Frankfort horizontal maxillary left first molar lost anchorage and tilted mesially. To correct
planeemandibular plane; IMPA, incisor to mandibular plane angle; LFH, lower facial height;
L1, lower central incisor; L6, lower first molar; Me, menton; N, nasion; NA, nasion point A;
this, a palatal TSAD was reinstalled to upright the tooth with modified
NB, nasion point B; NF, nasal floor; SN-MP, sella nasionemandibular plane; SNA, sella transpalatal arch and power elastics. To prevent canting of the
nasion point A; SNB, sella nasion point B; U1, upper central incisor; U6, upper first molar. transpalatal arms, a stainless steel ligature was also passively
38 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46

Fig. 4. Diagnostic setup models.

engaged on the maxillary right first molar (Fig. 7). In the finishing
stage, the mandibular second molars were bonded for
final adjustment. The patient also was advised to wear Class II elastics
(1/400 , 3.5 oz) from her maxillary left canine to her mandibular
second molar, and triangular elastics (3/1600 , 4 oz) from her maxillary
right canine to her mandibular canine and first premolar, along with
the midline elastics (5/1600 , 4 oz) from her maxillary right canine to
her mandibular left canine. A fixed first premolaretoefirst premolar
retainer was placed on the maxillary and mandibular arches. Essix
retainers were also delivered to secure the stability of both arches.
Because of the difficulty of the case, her total treatment time was
longer than expected: 3 years and 6 months, aggravated by several
missed appointments. (Figs. 8 and 9).
6. Treatment results
Posttreatment records revealed that the goal of improving her
gummy smile and closing the missing space without dental pros-
thesis were achieved. Facial photographs showed improved smile
esthetics. Class I molar relationship on the patient’s right side and
Class III molar relationship on her left side have been maintained. An
acceptable overbite and overjet were also achieved (Figs. 8 and 9).
 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46 39

Fig. 5. Intrusion of maxillary anterior teeth and retraction of mandibular anterior to the right-side teeth with TSADs. The TSAD on the anterior right segment was reinstalled from
between upper right (UR)1 and UR2 to between UR2 and UR3 due to mobility.

Fig. 6. Illustration of total intrusion of maxillary anterior and posterior dentition with TSADs. (A) Buccal crown torque and expansion on the maxillary posterior teeth to prevent side
effect as palatal tipping of the maxillary posterior teeth. (B) Maxillary anterior TSADs were used for intrusion and torque control of maxillary anterior teeth.
40 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46

Fig. 7. A TSAD and transpalatal arms were used for uprighting of the maxillary left first molar.

Fig. 8. Posttreatment facial and intraoral photographs.

 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46 41

Fig. 9. Posttreatment dental casts.

The posttreatment panoramic radiograph showed proper space
closure and acceptable root parallelism. There were no significant
signs of bone resorption, although anterior teeth demonstrated
signs of apical root resorption. She was referred to her oral surgeon
for the evaluation of the extraction of her horizontally impacted
mandibular third molar. She was also referred to a plastic surgeon
to determine whether botulinum toxin (Botox) therapy would
reduce her excessive gingival display, but she declined Botox ther-
apy (Figs. 8 and 10).
Posttreatment lateral cephalometric analysis and superimpo-
sition revealed slight skeletal changes (A point, nasion, B point:
6.5
, sella nasion to mandibular plane: 41.3
). The maxillary and
mandibular incisors showed retroclination (upper central incisor
to sella nasion line: 86.4
, incisor mandibular plane angle: 86.2
)
(Figs. 10 and 11, and Table 1). Facial aesthetic harmony was
achieved by retracting the maxillary and mandibular anterior
teeth and closing the mandibular plane following intrusion of the
maxillary posterior teeth and forward movement of the
mandible. The lower anterior facial height was slightly decreased,
and mentalis muscle strain was reduced. These overall changes
improved facial balance [17]. Because a significant amount of
overbite relapse and more than 80% of the total relapse of the
maxillary molars occurs during the first-year retention period
[18], the patient was asked to wear her retainers all the time. At
42 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46
Fig. 10. Posttreatment radiographs: (A) panoramic radiograph; (B) lateral cephalogram; (C) posteroanterior cephalogram.
the 2-year follow-up, the patient had a stable occlusion and the
results of the orthodontic treatment were maintained
(Figs. 12e14).
7. Discussion
The patient presented in this report was having a gummy smile
with deep overbite due to extrusion of maxillary anterior teeth.
Even though her upper lip showed normal position, her lower lip
was protrusive compared with the E-line. Her protrusive appear-
ance was due to backward and downward positioning/rotation of
mandible along with proclined mandibular incisors. Therefore,
closing of the spaces in the mandibular dentition will retrocline
the anterior dentition, and intrusion of the maxillary posterior
dentition will lead to a counterclockwise rotation of the mandible
to improve her profile. It was very difficult to control the torque of
maxillary anterior teeth during retraction because her maxillary
anterior teeth were initially upright to start with. A maxillary
palatal TSAD was used for intrusion of maxillary posterior teeth to
autorotate the mandible. A mandibular posterior unilateral TSAD
was used for retracting the mandibular anterior teeth toward the
right side to substitute the canine for the missing incisor and
closing all spaces.
Orthognathic surgery is an effective and predictable treatment
alternative to TSAD intrusion for correction of gummy smiles
resulting from dentoalveolar extrusion and VME [7,8]. However,
some patients are reluctant to undergo elective orthognathic sur-
gery due to its high cost and risk. Likewise, because our patient did
not want to have orthognathic surgery, camouflage treatment op-
tions were limited. We intruded the maxillary anterior and poste-
rior teeth with TSADs to reduce VME as much as possible. As a
result, approximately 5 mm at the maxillary incisor and approxi-
mately 1.5 mm at the maxillary molar intrusion were observed in
the lateral cephalometric measurements, and her gummy smile was
significantly reduced. Moreover, to improve her dental midline, it
was possible to move the mandibular dental arch approximately
6 mm to the right side with the help of a miniscrew. This case
report, along with other successful TSAD-assisted intrusion cases
[9e13], offers orthodontists and patients a more cost-effective,
lower-risk alternative to orthognathic surgery.
Although the risk associated with TSAD-assisted maxillary
intrusion is lower than the risk associated with orthognathic
 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46 43

Fig. 11. Cephalometric superimposition. Black, pretreatment; red, posttreatment. Solid line is right-side first molar, broken line is left-side first molar.

surgery, risk and limitations do still exist. TSADs are contra-
indicated in patients with bone metabolic disorders and in heavy
smokers [19]. As is the case with all orthodontic movement, root
resorption is an associated risk with TSAD-assisted maxillary
intrusion [20]. However, TSAD-assisted maxillary intrusion has
not been shown to cause more root resorption than other
methods of intrusion [16,21,22]. As is true with all orthodontic
cases, serial panoramic radiographs along with periapical radio-
graphs should be captured throughout active treatment to look
for changes in root length. Multiple studies show that root
movement into the maxillary sinus does not cause bone loss or
root damage [23e25]. Sinus perforations smaller than 2 mm will

Fig. 12. Two-year retention facial and intraoral photographs.

44 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46

Fig. 13. Two-year retention dental casts.

heal by themselves without complications [26,27]. Because most
TSADs are smaller than 2 mm in diameter, most asymptomatic
sinus perforations are not a concern and should heal without
intervention [16]. Kuroda and Tanaka [28] conclude that tooth
intrusion is a safe procedure, and limitations on movement have
not been identified.
Retention following maxillary intrusion should be considered
for long-term stability. Hsu and Liou [29] reported 30% relapse rate
14 months after miniscrew intrusion. Other studies [18,30] indi-
cated that most relapses following molar intrusion with TSADs
occur within the first year after treatment. To provide better
retention in the first year postintrusion, it is suggested to retain the
TSADs that were used for intrusion to anchor a clear retainer
[12,18]. Scheffler et al. [30] suggested that maxillary molar intrusion
with TSADs was effective to decrease long anterior facial height and
showed that maxillary first molars relapse 0.5-1.5 mm following
TSAD intrusion. On the other hand, intrusion of upper incisors with
TSADs was very effective compared with intrusion arch or J-hook
headgear, although further studies are needed for posttreatment
stability [14,22,31,32].
Surgical impaction of the maxilla as has the potential to relapse.
A study by Proffit et al. [33] reports that patients receiving superior
positioning of the maxilla experienced a 5-year relapse rate of 20%.
Although neither TSAD-assisted maxillary intrusion nor surgical-
assisted maxillary impaction can guarantee long-term stability,
both treatment modalities offer long-term success in 70% to 90% of
 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46
Fig. 14. Two-year retention radiographs: (A) panoramic radiograph; (B) lateral cephalogram; (C) posteroanterior cephalogram.
patients [29,33]. Proper diagnosis and treatment planning are
critical for successful impaction and retention [34].
Lip line can be excessively elevated due to a short upper lip
length or hyperactive lip elevator muscles. Measured from sub-
nasale to the most inferior portion of the upper lip at the midline,
the average lip length at rest is approximately 23 mm in men and
20 mm in women [3]. Excess gingiva displayed because of short
upper lip length can be corrected through lip reposition surgery
[35e37]. Hyperactivity of elevator muscles of the lip can be
reduced through surgery or botulinum toxin (Botox) therapy
[35,38e42].
The average height of the maxillary central incisors is 10.6 mm
in men and 9.8 mm in women [3]. Small clinical crowns, because of
hyperplastic gingiva or altered passive eruption, create a smile with
excess gingival display. Diagnosis of altered passive eruption is
done by determining the location of the cemento-enamel junction
(CEJ) in relation to the gingival margin. The CEJ should be just apical
to the gingival margin. If the CEJ is found to be excessively apical to
the gingival margin, altered passive eruption should be considered.
Altered passive eruption does not autocorrect; a gingivectomy is
necessary to remove the excess gingival tissue. To obtain a healthy
45
and stable result when performing a gingivectomy, it is important
to respect biologic width [43].
8. Conclusions
Gummy smiles can be a result of abnormal lip length/activity,
short clinical crowns, dentoalveolar extrusion, and VME. Each of
these factors requires a different treatment modality for correction.
Gummy smiles with a multifactorial etiology require a combination
of treatment modalities for correction. Both surgical-assisted
maxillary impaction and TSAD-assisted maxillary intrusion can
improve gummy smiles in cases of dentoalveolar extrusion and
VME. In appropriately selected cases, TSAD-assisted maxillary
intrusion can effectively reduce a gummy smile without orthog-
nathic surgery and result in an esthetic outcome.
Acknowledgments
We thank Brent Jorgensen for his help with the preparation of
the manuscript. The authors have no other financial relationships to
disclose.
46 S. Uzuka et al. / Journal of the World Federation of Orthodontists 7 (2018) 34e46

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