CASE REPORT

Adult Class II Division 1 patient with severe

gummy smile treated with temporary anchorage
devices
Rui Shu,a Lan Huang,b and Ding Baic
Sichuan and Chongqing, People's Republic of China

A 23-year-old Mongolian woman came for a consultation with chief complaints of protrusive lips and a gummy
smile. The clinical examination showed a convex profile, a protrusive maxilla, excessively proclined and ex-
truded maxillary incisors, and a Class II Division 1 malocclusion. Temporary anchorage devices (TADs) in the
posterior dental region were used as anchorage for the retraction and intrusion of her maxillary anterior teeth.
Those appliances, combined with a compensatory curved maxillary archwire, eliminated the severe gummy
smile and the protrusive profile, and corrected the molar relationship from Class II to Class I. With no extra tem-
porary anchorage devices in the anterior region for intrusion, the treatment was workable and simple. The patient
received a satisfactory occlusion and an attractive smile. (Am J Orthod Dentofacial Orthop 2011;140:97-105)

T
emporary anchorage devices (TADs) have changed
the conventional conception of anchorage control
and biomechanics in orthodontics. They have re-
placed many traditional types of mechanics and simpli-
fied orthodontic treatment. In 1983, Creekmore and
Eklund1 reported a patient with a deep overbite cor-
rected with a Vitallium bone screw; it was the first report
of the clinical use of TADs. Based upon the extensive ap-
plications of TADs, many appliances have been invented
to solve orthodontic problems, such as a protrusive alve-
olus and a significant gummy smile. Gummy smile refers
to excessive gingival display during full smile. The cur-
rent opinion is that less than 2 mm of gingival exposure
is more esthetic and youthful.2-4 Kim et al5 and Kim and
Freitas6 introduced a Class II Division 2 patient treated
with a segmental arch appliance with TADs, which
a
Postgraduate student and PhD candidate, State Key Laboratory of Oral Diseases,
Department of Orthodontics, West China Stomatology Hospital of Sichuan Uni-
versity, Chengdu, Sichuan, People's Republic of China.
b
Orthodontist, Department of Orthodontics, The Affiliated Hospital of Stomatol-
ogy, Chongqing Medical University, Chongqing, People's Republic of China.
c
Professor and department chair, State Key Laboratory of Oral Diseases, Depart-
ment of Orthodontics, West China Stomatology Hospital of Sichuan University,
Chengdu, Sichuan, People's Republic of China.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Ding Bai, State Key Laboratory of Oral Diseases, Department
of Orthodontics, West China Stomatology Hospital of Sichuan University, 14#,
3rd section of Renmin South Road, Chengdu 610041, People’s Republic of China;
e-mail, baiding@scu.edu.cn.
Submitted, December 2010; revised and accepted, January 2011.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.01.021
corrected the excessive vertical growth of the maxillary
anterior dentoalveolar complex and alleviated the
gummy smile. Lin et al7 reported on 4 patients with
gummy smiles treated by a combination of TADs and
periodontal surgery without orthognathic surgery. But
there has been no case report of TADs used in the treat-
ment of a Class II Division 1 patient with a significant
gummy smile.
In this case report, we aimed to introduce the treat-
ment of a woman with a Class II Division 1 malocclusion.
TADs with compensatory curved archwires corrected the
patient’s protrusive profile and significant gummy smile.
DIAGNOSIS AND ETIOLOGY
The patient, a 23-year-old Mongolian woman, had
a convex profile and a Class II malocclusion. Her chief
complaints were protrusive lips and a gummy smile.
The photographs taken before treatment showed
protrusive upper and lower lips, both of which exceeded
the E-line and were strained on closure (Fig 1). No
anomaly was seen in the frontal facial photos, except
that the patient was overly cautious about smiling nat-
urally. When the patient relaxed, we took another smil-
ing image (Fig 2), which showed a significant gummy
smile with more than 4 mm of gingival exposure in the
incisor region. The photographs and pretreatment study
casts (Fig 3) exhibited excessively proclined and extruded
maxillary incisors, and cusp-to-cusp canine and molar
relationships with a deep overbite and overjet and no ap-
parent crowding. The clinical examination suggested
97
98 Shu, Huang, and Bai

Fig 1. Pretreatment photographs.

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 in our clinical examination that could be the
etiology of the gummy smile.8-10
A cephalogram (Fig 4, A) and a panoramic radio-
graph (Fig 4, C) were taken before treatment. The ceph-
alometric analysis (Table) and the tracing (Fig 4, B)
demonstrated a Class II skeletal relationship (ANB, 6 )
as a result of the retruded mandible. The A-point was
in the normal range (SNA, 80 ), and B-point was ret-
ruded (SNB, 74 ). The angle between the maxillary inci-
sors and the S-N plane was 112 , and the IMPA was
101 , which indicated that the protrusive profile was Fig 2. Pretreatment smiling photographs.
mainly caused by the proclined maxillary anterior teeth.
TREATMENT ALTERNATIVES
TREATMENT OBJECTIVES Three alternatives were presented to the patient.
The treatment objectives were to create a satisfactory 1. Combined surgical and orthodontic treatment to
occlusion with a Class I molar relationship and normalize harmonize the molar relationship with extraction
overjet and overbite. Retraction and intrusion of the of premolars in both the maxilla and the mandible.
maxillary anterior teeth were indicated to reduce the ex- Orthognathic surgery could be used to elevate and
posure of the gingiva and the protrusive profile. Simul- retrude the anterior maxillary dentoalveolar part to
taneously, extrusion of the posterior teeth would be eliminate the gummy smile and improve the profile.
limited to prevent a clockwise rotation of the mandible Advancement genioplasty could be used to camou-
and an increase in lower facial height. flage the retruded mandible and improve the profile.

July 2011  Vol 140  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Shu, Huang, and Bai
Fig 3. Pretreatment study casts.
2. Harmonize the molar relationship and retract the
anterior teeth by extracting the maxillary first pre-
molars and the mandibular second premolars. Use
TADs to provide absolute anchorage for maximum
retraction of the proclined maxillary teeth and max-
illary incisor intrusion to eliminate the gummy
smile. The disadvantage was that the retruded man-
dible would not be corrected.
3. Extract the maxillary first premolars and the man-
dibular second 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 cooperation.
After we discussed these alternatives with the patient,
she chose the second option. She considered the
improvement from orthognathic surgery not worth the
additional cost and risk, and the headgear was
unacceptable.
TREATMENT PROGRESS
Orthodontic treatment began on February 28, 2006,
and lasted for 38 months. Before bracket bonding, the
maxillary first premolars and mandibular second premo-
lars were extracted. Two mini-implants (1.6 3 9 mm,
Aarhus, Medicon, Tuttlingen, Germany) were placed
American Journal of Orthodontics and Dentofacial Orthopedics
99
between the roots of the maxillary second premolars
and first molars, 3 mm occlusally to the buccal frenum.11
Preadjusted 0.022-in brackets (Shiye, Hangzhou,
China) were bonded to all teeth. With sequential
nickel-titanium archwires, alignment and leveling
were achieved in 9 months. Then, 0.018 3 0.025-in
stainless steel wires were placed in both dental arches.
The maxillary wire had a 5-mm compensating curve of
Spee. Nickel-titanium closed-coil springs and Class II
elastics were used for space closure and mesial mandib-
ular molar movement (Fig 5, A). In the 20th month of
treatment, the mandibular space was closed, and the
first molars were in a Class I relationship. Further max-
illary retraction was achieved by nickel-titanium closed
coil springs on the TADs (Fig 5, B). After 4 months of
retraction of the maxilla, both overbite and overjet
were reduced. No Class II elastics were used during
the final maxillary retraction. At the third stage, the
second molars were bonded, and intermaxillary elastics
were applied with 0.018-in stainless steel wires in the
brackets for better interdigitation of the occlusion
(Fig 5, C).
The total treatment time was 3 years 4 months. It
took approximately 9 months to close the mandibular
space and over 20 months to retract and intrude the
maxillary anterior teeth.
July 2011  Vol 140  Issue 1
100 Shu, Huang, and Bai

Fig 4. A, Pretreatment cephalogram; B, cephalometric tracing; and C, panoramic radiograph.

TREATMENT RESULTS Table. Cephalometric data

The posttreatment photographs (Fig 6) showed a re- Norm Pretreatment Posttreatment D
markable improvement in lip profile from the significant SNA ( ) 83.13 6 3.6 80 79 1
retraction of the anterior teeth. Meanwhile, there was no SNB ( ) 79.65 6 3.2 74 74 0
gummy smile at the posttreatment clinical examination. ANB ( ) 3.48 6 1.69 6 5 1
The posttreatment photographs (Fig 6) and dental casts FMA ( ) 29 6 5 34 36 2
U1 to SN ( ) 102 6 5.4 112 99 13
(Fig 7) demonstrated Class I canine and molar relation- IMPA ( ) 97 6 6 101 92 9
ships with normal overbite and overjet. The posttreat- Interincisal 126.96 6 8.54 105 124 19
ment cephalogram and panoramic radiograph are angle ( )
shown in Figure 8. The cephalometric analysis (Table)
and superimposition (Fig 8, B) showed no change in
the position of the maxillary molars. The incisal edge DISCUSSION
of the maxillary incisors was retracted by 7 mm and in- Gummy smiles can be classified by etiology into soft-
truded by 2.5 mm, and the mandibular first molars tissue,3 dentoalveolar, and skeletal types.6,8-10 The
moved 3.5 mm mesially. Normal overbite and overjet skeletal type is caused by excessive vertical maxillary
were achieved. The maxillary anterior alveolar bone growth and is found in patients with long-face syn-
and gingiva moved lingually and upward with the tooth drome. Orthognathic surgery is generally required to
movement. However, the final cephalometric analysis treat this problem.8,12 However, in some dentoalveolar
(Table) showed that the skeletal discrepancy between cases, orthognathic surgery could produce an
the maxilla and the mandible remained unchanged. unfavorable result. For the patient whose gummy smile
The comparison between the pretreatment and post- is derived from protrusion and extrusion of the
treatment panoramic radiographs showed no apparent maxillary anterior dentoalveolar complex, decreased
root shortening. anterior dentoalveolar height after surgery might result

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Shu, Huang, and Bai
Fig 5. Treatment progress: A, combination of nickel-titanium closed-coil springs and Class II elastics;
B, nickel-titanium closed coil springs on the TADs for further maxillary retraction; and C, intermaxillary
elastics for better occlusion.
in a low smile.13 These considerations, plus the favorable
outcome of the selected treatment, suggested that or-
thognathic 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.
Two mandibular second premolars were extracted in-
stead of 2 mandibular first premolars, because mandib-
ular first premolar extractions might increase the
difficulty of mesial movement of the mandibular molars.
The selected alternative, extraction of the maxillary first
premolars and mandibular second premolars, which
ameliorated the profile and molar relationship, is a classic
treatment modality for a Class II Division 1 patient.
For this patient, the convex profile and gummy smile
were both caused by excessive protrusion of the maxil-
lary anterior dentoalveolar complex. Thus, maximum re-
traction of the maxillary anterior teeth was needed. To
meet this purpose, anchorage control was emphasized
throughout the treatment.
American Journal of Orthodontics and Dentofacial Orthopedics
101
Before the development and application of TADs, or-
thodontists’ choices were limited to appliances such as
transpalatal arches, Nance arches, and headgears.14
These appliances have disadvantages, such as their unes-
thetic appearance, undesirable intermittent forces, and
dependence on patient cooperation. Also, mesial move-
ment of the molars was inevitable even with these appli-
ances. Correction of gummy smiles with continuous
light intrusion forces on the maxillary anterior dental
arch3,15 could be accomplished by extraoral intrusion
appliances such as headgear16 and J-hook.17 Traditional
intrusion techniques, such as utility arches18 and 1-piece
intrusion arches,19 were not optimal for this patient, be-
cause they require anchorage on the molars and produce
undesirable moments on the anterior teeth.
The first clinical case report about TADS was pub-
lished in 1983. Creekmore and Eklund1 used a Vitallium
bone screw in treating a patient with a deep overbite.
But TADs were not accepted immediately. TADs have
gradually become more acceptable and are now used
in solving orthodontic problems. Currently, several cases
July 2011  Vol 140  Issue 1
102 Shu, Huang, and Bai

Fig 6. Posttreatment photographs.

Fig 7. Posttreatment study casts.

July 2011  Vol 140  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Shu, Huang, and Bai
Fig 8. A, Posttreatment cephalogram; B, superimposition; and C, panoramic radiograph.
have been reported in the literature with TADs for en-
masse retraction. With time, TADs are gradually replac-
ing the aforementioned appliances and have become
the preferred anchorage option for orthodontists.
The development of TADs has triggered various novel
techniques for treating gummy smiles. Kim et al5 intro-
duced a segmental archwire assisted by placing TADs be-
tween 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 al7 reported on 4 patients with skeletal gummy
smiles treated with a combination of TADs and peri-
odontal surgery. But there have been no reports of a Class
II Division 1 patient with a gummy smile treated with
TADs.
For Class II Division 2 patients, TADs in the anterior
alveolus could provide an intrusion force and proclining
moments on the maxillary incisors; this is ideal for ex-
truded and retruded teeth. But in our Class II Division
1 patient, the gummy smile was caused by protrusion
and excessive vertical growth of the anterior dentoalveo-
lar complex. Therefore the mechanical system for Class II
Division 1 patients should be different. TADs in the
American Journal of Orthodontics and Dentofacial Orthopedics
103
anterior alveolus were not appropriate. We adopted
TADs between the maxillary second premolars and first
molars combined with nickel-titanium closed-coil
springs that could provide a continuous total force pass-
ing near the center of resistance of the 6 anterior
teeth.16,20-23 The force could be divided into 2 parts:
a greater horizontal force for retraction of the
protrusive anterior dentoalveolar complex and
a smaller vertical force for intrusion of the anterior
teeth (Fig 9, A).
The smaller vertical force was suitable and enough to
meet the need for anterior tooth intrusion. This appli-
ance is simple and workable in the treatment of patients
with gummy smiles and Class II Division 1 malocclusion.
On the other hand, this mechanical system is also sug-
gested for the Class II Division 1 patient who has a low
or average smile.13 However, the intrusion force pro-
duced by TADs during en-masse retraction will reduce
the exposure of the maxillary teeth, and this would
aggravate an unesthetic smile.
However, orthodontists have found that the TADs
technique could not completely eliminate anchorage
loss. One reason is that the force on the traction hook
July 2011  Vol 140  Issue 1
104 Shu, Huang, and Bai

Fig 9. Mechanical analysis. A, Force system involved: F, total force; V, vertical force; H, horizontal
force (H was much greater than V ); CR, center of resistance. B, Couples induced by deformation of
the archwire.

will cause deformation even with stainless steel archwires;
it also creates couples, inducing mesial tipping of the mo-
lars and lingual tipping of the anterior teeth (Fig 9, B).
A finite element analysis of TADs used for en-masse re-
traction also showed that the inclination of the incisor
would be reduced without torque control even when the
total force passed through the center of resistance of the
6 anterior teeth.24 To ensure maximal retraction and pre-
vent 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 an-
terior teeth also prevented the roots from approximating
the cortical plate, which, when combined with continuous
light retraction forces, effectively reduced root resorp-
tion.3,25 The posttreatment radiographs might have
underestimated root resorption but did not show any
apparent root shortening.26 The treatment with our
appliance produced a satisfactory outcome.
CONCLUSIONS
TADs and a curved archwire were adopted for the
treatment of a 23-year-old woman with protrusive lips
and a gummy smile, and a desirable result was achieved.
1. The protrusive anterior dentoalveolar complex and
excessively erupted anterior teeth were corrected
by retraction and intrusion of the anterior dental al-
veolus; this eliminated the gummy smile and the
protrusive profile.
2. For intrusion of the maxillary anterior teeth in Class
II Division 1 patients, posterior TADs provide more
optimal force than TADs placed in the anterior part.

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Shu, Huang, and Bai
3. When TADs are used for en-masse retraction in
a Class II Division 1 patient with a low smile, aggra-
vation of the unesthetic smile is caused by an intru-
sion force from the TADs and should be avoided.
4. The appropriate application of TADs to correct
a gummy smile must be based on the correct anal-
ysis of the etiology.
5. The compensatory curve played an important role in
anchorage control of the molars, torque control of
the anterior teeth, and correction of the deep over-
bite.
6. This appliance was simple and workable for the
treatment of a Class II Division 1 patient with
a gummy smile, and she was satisfied with the result.
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