|Year : 2019 | Volume
| Issue : 4 | Page : 531-538
|Smile changes after intrusion of maxillary incisors with temporary anchorage devices (TADs) or accentuated compensating curve arch wire
Nahla Elsayed Gomaa1, Neveen Mohamad Fakhry1, Ghada Abdelfattah Elmehy1, Mona A Montasser2
1 Department of Orthodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt
2 Department of Orthodontics, Faculty of Dentistry, Mansoura University, Mansoura, Egypt
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|Date of Submission||17-Jun-2017|
|Date of Decision||06-Sep-2017|
|Date of Acceptance||27-Oct-2017|
|Date of Web Publication||18-Nov-2019|
| Abstract|| |
Objective: The aim is to evaluate changes of smile and gingival line after intrusion of maxillary incisors using mini-implant anchorage system or conventional accentuated compensating curve archwire. Materials and Methods: Twenty participants having deep overbite with age ranged from 18 to 24 years were enrolled in this study and were divided into two groups of 10 each. Intrusion of maxillary incisors was performed using mini-implant anchorage system in group 1 and by conventional accentuated compensating curve archwire in group 2. For each participant, lip position, dental and skeletal measurements related to the gingival line were recorded from standardized photographs and cephalometric analyses. Statistical analyses including t-test and Chi-square were used to evaluate differences between groups. Results: There was an improvement of smile arc (consonance) from 30% smile consonance pretreatment to 90% consonance postintrusion in group 1, but the change was insignificant in Group 2. There was an increase in the outer intercommisural width in Group 2 compared to group 1 with a significant difference between both groups (P < 0.046). A significant decrease in the upper lip to upper incisal edge relationship in Group 1 and an insignificant decrease in Group 2 (P = 0.03 and P = 0.262, respectively) was detected. A significant decrease in overbite in Group 1and in Group 2 (P = 0.001) with an insignificant difference between both groups (P > 0.05) was also observed. Conclusion: Smile improvement in the mini-implant group was mainly the result of improved smile arc, increase in outer intercommisural width, decrease in upper lip to upper incisal edge relationship, and decrease in overbite. With the use of accentuated compensating archwires, the only significant change was increase in the interlabial gap.
Keywords: Intrusion, mechanics, smile
|How to cite this article:|
Gomaa NE, Fakhry NM, Elmehy GA, Montasser MA. Smile changes after intrusion of maxillary incisors with temporary anchorage devices (TADs) or accentuated compensating curve arch wire. Indian J Dent Res 2019;30:531-8
|How to cite this URL:|
Gomaa NE, Fakhry NM, Elmehy GA, Montasser MA. Smile changes after intrusion of maxillary incisors with temporary anchorage devices (TADs) or accentuated compensating curve arch wire. Indian J Dent Res [serial online] 2019 [cited 2021 May 11];30:531-8. Available from: https://www.ijdr.in/text.asp?2019/30/4/531/271057
| Introduction|| |
Improvement of the dentofacial esthetics is the most common reason for the patients to seek orthodontic treatment., Malocclusion leads to bad esthetics which in turn affect patients' self-confidence negatively. Hence, balance between the teeth, intraoral, and extraoral soft tissues during smiling is of great importance. Definition of beauty has been a controversial topic throughout history and many studies had focused on evaluation methods of beauty., Facial attractiveness can be determined by smile “the window of interpersonal communication and social interactions.”
Smile can be divided into 2 types; social and enjoyment smiles. A social smile is the voluntary smile a person uses in social settings or when posing for photographs. Social smile is considered as a static facial expression. On the other hand, enjoyment smile is involuntary and is elicited by laughter; as the mouth bursts forward to give maximal expansion of the lips, it appears strained. Enjoyment smile cannot be sustained. The reliable reference for smile measurements is the unstrained social smile as that used in the orthodontic photographs.
The smile happens in two stages; in the first stage, the upper lip is raised to the nasolabial fold by contraction of the elevator muscles embedded in the upper lip and begin in the fold. Lip at the anterior teeth is raised by the median muscle bundles, whereas the lateral muscle groups raise the lip at the posterior teeth. At this point, the lip meets resistance at the nasolabial fold because of cheek fat. In the second stage, further raising the lip and the fold superiorly is involved by three muscle groups; the levator labii superior muscles of upper lip, starting at the infraorbital region, the zygomaticus major muscles, and the superior fibers of the buccinators.
Peck et al. divided the smile into three groups; a low smile in which <75% of maxillary anterior crown height is displayed, an average smile exposing 75%–100% of maxillary anterior crown height, and a high smile displaying a band of the contiguous maxillary gingiva.
Smile esthetics after orthodontic treatment is influenced by buccal corridors, incisor protrusion, smile arc, and gingival display. Buccal corridor can be defined as a negative space created between the buccal surfaces of posterior teeth and the inner wall of the cheek. Smile arc is defined by the relation between the incisal edge curvature of the maxillary anterior teeth and the curvature of the upper edge of the lower lip. When these curvatures are parallel, the smile is considered “ideal” or “consonant smile.” “Nonconsonant smile” occurs when the incisal edge curvature of the maxillary incisors is flatter than curvature of the upper edge of the lower lip.
Gummy smile has been also described as high smile, full denture smile, or short upper lip. It is generally considered esthetically undesirable and used to be given more consideration by orthodontists and surgeons. Hence, several treatment modalities have been suggested including orthodontic treatment combined with maxillary superior repositioning surgery (LeFort I osteotomy) to reduce vertical maxillary excess. However, this approach has limitations as the upper lip tends to be shortened by 50% of surgical skeletal intrusion., Another approach is to remove the collar of excess gingiva surgically to expose more of clinical crown and reduce gummy smile.,,,,,, Furthermore, another approach is to inject self-curing silicone implant to the anterior nasal spine to camouflage the subnasal mass resulting in upper lip elevation restriction during smiling and hence reducing gummy smile.,
The position of the maxillary incisors relative to the upper lip is a key factor in determining the type of treatment of gummy smile. Deep bite patients with at least a 4 mm coverage of the maxillary incisors by the lower lip and a gummy smile could be treated with intrusion of the maxillary incisors., Intrusion can be defined as the apical movement of the centroid (geometric center of the root) in respect to occlusal plane or a plane based on the long axis of tooth. Intrusion of maxillary anterior teeth with significant reduction of overbite by orthodontic treatment is also one of the approaches used to improve gingival smile line. Upper incisors intrusion can be achieved by J-hook headgear, utility arch, reverse curved arch, continuous intrusion arches with segmented arch technique, 3-piece intrusive arch, Connecticut intrusion arch, or Begg technique.,, The reverse curve of Spee as described by Tweed, 1966 is a continuous arch that helps to extrude premolars and molars with as well as intrusion of the incisors.
Data regarding the effect of maxillary incisors intrusion on smile in cases with deep bite is insufficient so, the objective of this study was to evaluate smile changes after intrusion of maxillary anterior teeth either using mini-implant anchorage system or conventional accentuated compensating curve archwire.
| Materials and Methods|| |
This retrospective study was performed after receiving the approval of the ethical committee of Faculty of Dentistry, Tanta University. The data presented in this study were collected from orthodontic records taken for 20 patients who sought orthodontic treatment in the Department of Orthodontics. To determine the sample size, we presumed that gummy smile would be decreased by 20% after intrusion of maxillary incisors by temporary anchorage devices (TADs) compared to conventional accentuated compensating curve archwire. It was estimated that enrollment of 8 participants for each group will be required to permit a type 1 error of α = 0.05 with a power of 80%. Ten participants were enrolled for each group to compensate for any dropouts during the work. The following criteria were used for inclusion in the study: (1) age 18–24 years, (2) Angle Class I or II malocclusions (however, all cases had skeletal Class I relationship) before treatment with no severe skeletal discrepancy, (3) deep overbite (more than 4 mm) due to extruded upper incisors with increased gingival display on smiling, (4) permanent dentition, (5) no medical or dental contraindications for orthodontic treatment, (6) no previous orthodontic treatment, and (7) good oral hygiene.
The participants were divided into two groups; each group consisted of 10 participants. Group 1: (1 male and 9 females); 4 participants had Class I and 6 participants had Class II malocclusion and they were treated by mini-implant anchorage system as a TADs. The TADs used were of 1.3–1.6 mm diameter and 6–8 mm length, AbsoAnchor orthodontic microimplant, Dentos, South Korea. TADs were inserted in the attached gingival [Figure 1]a. One month after mini-implant insertion, a stainless steel archwire (0.016″×0.022″) with anterior crimpable hooks distal to the lateral incisors was placed in the maxilla as described before. Group 2 consisted of 1 male and 9 females; 8 of them had class I and 2 cases had class II malocclusion and they were treated by archwire with reverse curve of Spee [Figure 1]b for intrusion of maxillary incisors after teeth leveling and alignment. The archwire sequences that was used in group 2 was as follows: maxillary accentuated compensating curve archwires (round and rectangular) were used in a sequence initiated by 0.016″ nickel-titanium, followed by 0.016″×0.016″, 0.016″×0.022″, and then 0.017″×0.025″ nickel-titanium archwires.
|Figure 1: The used techniques: (a) Mini-implant anchorage system (b) Accentuated curve of Spee|
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A complete set of records including a full frontal smile photograph, skeletal and dental measurements on lateral cephalometric X-ray films before treatment and just after intrusion of the maxillary incisors were used. All photographs were obtained with a Sony DSC-W120 digital camera (Sony Japan, Sony Corporation) with the focal distance standardized at 12″ from the participant with a 1:2 magnification ratio. For each participant, variables which describe lip position and other dental and skeletal measurements related to the gingival smile line were collected and analyzed. The linear measurements were made on rest and smile photographs, whereas dental and skeletal parameters [Table 1] and [Figure 2], [Figure 3], [Figure 4] were measured on lateral cephalometric X-ray films according to the methods described.,,,
|Figure 2: (A and B) Rest position linear measurements. (a) upper lip length. (b) upper lip thickness. (c) interlabial gap. (d) outer intercommissural width. (e) commissural height. (C, D) Smile photograph linear measurements. (a) upper lip length. (b) upper lip thickness. (c) interlabial gap. (d) outer intercommissural width. (e) commissural height|
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|Figure 3: (A) Measuring the upper lip smile line. (B) Smile photograph linear measurements. (a) upper lip to upper incisor edge. (b) Rt buccal corridor space. (c) Lt buccal corridor space. (C): Smile arc|
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|Figure 4: Skeletal cephalographic measurements. (1) SN-Mandibular plane (in degrees). (2) SN-Palatal plane (in degrees). (3) Palatal plane-incisor centroid (PL-CR) (in millimeters)|
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The variables were re-measured after 2 weeks by one of the coauthors, and the readings of the first estimation were compared to the second one. Casual errors were calculated according to Dahlberg's formula  Se 2= ∑d 2/2n was used to determine the casual errors where (Se 2) is the error variance, (d) was the mean difference between repeated measurements, and (n) was the number of measurements. Paired t-test and Chi-square were used to analyze the data. Paired t-test was used to compare pretreatment and postintrusion measurements in the same group and two samples t-test was used to compare variables between groups. Chi-square test was used to evaluate the percentage of smile arc as it has no numerical values, only consonant or none.
| Results|| |
Dahlberg's errors were small and negligible (0.19 mm to 0.28 mm and 0.25° to 0.49° for linear and angular measurements, respectively).
Descriptive statistics and comparison of the measured parameters for both groups are listed in [Table 2] and [Table 3]. The photographic analysis of the rest position measurements in group 1 revealed that there was no significant differences (P > 0.05) in upper lip length, upper lip thickness, interlabial gap, and commissural height between pretreatment and postintrusion stage. On the other hand, there was significant increase in the outer intercommisural width. While, in Group 2, there were no significant differences in any measured photographic rest position variables between pretreatment and postintrusion stage. Regarding photographic smile measurements in group 1, there were no significant differences for most of the variables at (P < 0.05). On the other hand, there was a significant decrease in the U lip-U1 measurement. In group 2, there was a significant increase of the interlabial gap at (P < 0.05), whereas, there was no significant change in the other photographic smile measurements.
|Table 2: Changes in the photographic (rest position and smile), and dental and skeletal measurements after incisor intrusion in Group I|
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|Table 3: Changes in the photographic (rest position and smile), dental and skeletal measurements after incisor intrusion in Group II|
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Cephalometric analysis of the dental and skeletal changes in group 1 showed a significant decrease in overjet at P < 0.05 and significant reduction of overbite (2.8 mm) (P < 0.001). Furthermore, significant change in the vertical position of the centroid point CR, palatal plane-incisor centroid (PL-CR) was observed (P < 0.05). However, there were insignificant differences in the clinical crown height of U1, SN/MP, and SN/PL angles. Significant decrease in the overbite by 2.7 mm (P < 0.001) was seen in group 2. However, the overjet and PL-CR distance (upper intrusion) decreased insignificantly. No significant differences of the clinical crown height of U1, SN/MP, and SN/PL angles were observed after intrusion period in Group 2.
The smile arc evaluation for the participants in Group 1 showed a significant improvement of smile arc from 30% to 90% after incisor intrusion, that is, the smile line was parallel to the lower lip after orthodontic treatment. On the other hand, a nonsignificant improvement of smile arc after intrusion period was recorded in group 2. The difference between the two studied groups was significant (P < 0.05) [Table 4].
|Table 4: Smile arc changes in the photographic smile measurements after incisor intrusion in Group I and Group II|
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Comparing the rest position and smile photographs between the two studied groups revealed a significant difference in the mean amount of outer intercommisural width after intrusion of the maxillary incisors. Significant increase in the outer intercommisural width was observed in the mini-implant group than in the accentuated compensating curve archwire group (P < 0.05). While in photographic smile measurements, the outer intercommisural width and the interlabial gap showed significant increase in Group 2 compared with group 1. The UL-U1 distance decreased significantly (P < 0.05) in Group 1 more than in Group 2. The other variables did not show any significant differences between Group 1 and Group 2 [Table 5].
|Table 5: Comparison of the photographic (rest position and smile), dental, and skeletal mean changes between Group I and Group II|
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The amount of intrusion of the maxillary incisors (PL-CR distance) was greater in Group 1 than Group 2 by 0.3 mm. The difference was not statistically significant. Furthermore, there was no significant difference of the overbite, SN/MP, and SN/PL measurements between the two studied groups. However, overjet showed significant decrease in group 1 compared with Group 2 (P < 0.05).
| Discussion|| |
Intrusion of maxillary anterior teeth with significant reduction of overbite by orthodontic treatment is one of the approaches used to improve high smile line. The age range of the 20 subjects selected for the present study was between 18 and 24 years to eliminate the growth effect.
Analysis of rest position results in Group 1 revealed that there were no significant differences in upper lip length, upper lip thickness, interlabial gap, and commissural height between pretreatment and postintrusion stage, whereas a significant increase in the outer intercommissural width was found. On the other hand, in Group 2, there were no significant differences in any measured photographic rest position variable between pretreatment and postintrusion stages. Analysis of the measurements in Group 1 revealed a significant decrease in the U lip-U1 measurement, but no significant differences for most of the variables was found. In Group 2, a significant increase of the interlabial gap was demonstrated with insignificant changes in the other smile measurements. The previous studies are in agreement with those of the present study in that lip length, and smile line are affected by musculature and anatomy of patients so, the extent of improvement of smile with orthodontic treatment is limited.,, Regarding lip thickness, the results of the previous studies are in agreement with those of the present study in that no statistically significant changes were found between pre- and posttreatment in both groups. Relation between gummy smile and esthetics of smile was studied by numerous investigators.,,,,, Their results are in line with those of the present study in that when 0 mm gingival display was found, the smile was more attractive.
The results of this study showed a significant difference in smile arc between both of the studied groups. Postintrusion smile arc was significantly different compared to pretreatment; the smile line became parallel to the lower lip after orthodontic intrusion of the maxillary incisors. Improvement of smile arc in Group 1 was significant after incisor intrusion. These results are also in agreement with a previous study, in which ideal smile arc and a small buccal corridor gave high smile scores. Other studies , revealed that flat smile arcs had lower smile scores while buccal corridors did not affect smile scores. On the other hand, the previous studies , showed that negative spaces or buccal corridors did not affect smile esthetic for nonspecialists and orthodontists.
CR has been reported not to be affected by tooth inclination change, so it was considered as a point of choice to clarify if true intrusion has occurred or not. The results obtained in group 2 showed no statistically significant difference in clinical crown height.,,, A significant decrease in overbite was found between preintrusion and postintrusion results in both groups with an insignificant difference between both groups. This reduction can be attributed to either intrusion of the maxillary incisors or incisor protrusion and/or extrusion of the molars. As SN/MP and U1/SN angles showed no significant change, it may be suggested that absolute intrusion of the incisors without molar extrusion or incisor proclination was what happened in group 1. These results are in agreement with the previous reports.,,, In group 2, overbite reduction was attributed to a combined effect of maxillary incisor intrusion and protrusion and also molar extrusion. Other studies used other different archwires for intrusion and their results are in agreement with those of our study.,
Overjet decreased significantly in group 1 compared to group 2. This decrease could be explained by the difference in axial inclination of the upper incisors between the two groups. There was a significant proclination of maxillary incisors in group 2 more than in group 1, and this also is in agreement with the previous studies.,, However, other studies found insignificant increase in overjet that may be attributed to the differences in the mechanics used. Further Studies with a larger sample size are recommended to enhance reliability of the results. It would be even better to improve the homogeneity of the sample by selecting participants with the same Angle's classification.
| Conclusion|| |
Smile improvement in the mini-implant group was mainly the result of improved smile arc, increase in outer intercommisural width, decrease in upper lip to upper incisal edge relationship, and decrease in overbite. With the use of accentuated compensating archwires, the only significant change was increase in the interlabial gap.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Nahla Elsayed Gomaa
Department of Orthodontic, Faculty of Dentistry, Tanta University, Tanta
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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