TREATMENT DETERMINANTS OF THE GINGIVAL SMILE

Jessica H. Cox, D.D.S.

An Abstract Presented to the Faculty of the Graduate School of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry 2010

ABSTRACT Objective: The purpose of this study is to determine

which dental, skeletal, and soft tissue characteristics affect lip height and which characteristics affect lip height changes during treatment. Materials and Methods:

Models for 200 randomly selected subjects were obtained and used to calibrate the smiling photographs of each subject. The photographs were then measured to determine the change in gingival display that occurred during treatment. The change in gingival display was used to create three groups: those that obtained the greatest increase, greatest decrease, and average change in gingival display. The cephalometric radiographs were then traced for each subject and digitized. The pre and post treatment cephalometric radiographs of each subject were superimposed and a total of 54 linear measures were made at each time point. The measures were then compared using t-tests for intra-group changes from T1 to T2 and an Analysis of Variance (ANOVA) for inter-group comparisons at each time point. Results: There were no significant differences between the Paired t tests

groups at the pretreatment time point.

revealed significant differences in 25 of the 27 vertical measures within all groups from the pre treatment to post-

treatment time points.

The horizontal measures indicated

more significant differences in the backward direction in the greatest increase group than the other two groups. The significant vertical difference between the groups at the post-treatment time point was found between the average change group and the greatest increase group at condylion. The significant horizontal differences between the groups were found between the greatest increase and greatest decrease groups at the soft tissue lips. The lips moved

significantly backward in the greatest increase group while they stayed relatively the same in the greatest decrease group. Conclusions: No pretreatment characteristic could be

identified to predict the tendency to experience an increase or decrease in gingival display during orthodontic treatment. The lips moved significantly backward in the

group that experienced an increase in gingival display while they stayed relatively the same in the group that experienced a decrease. Although not significant, other general tendencies were apparent between the two extreme groups. Further research is warranted.

TREATMENT DETERMINANTS OF THE GINGIVAL SMILE

Jessica H. Cox, D.D.S.

A Thesis Presented to the Faculty of the Graduate School of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry 2010

COMMITTEE IN CHARGE OF CANDIDACY: Professor Rolf G. Behrents, Chairperson and Advisor Professor Eustaquio Araujo Assistant Professor Ki Boem Kim

DEDICATION To my loving husband, Wynne, who has made many sacrifices to support me in my academic endeavors and whose constant encouragement has enabled me to work through even the most stressful times. To my parents, who have encouraged me to strive for excellence and have convinced me that, with work, I can achieve any goal. Everything I have accomplished is due to

the confidence they have instilled and the encouragement they continue to show. To my family and friends, who have loved and supported me throughout my education.

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ACKNOWLEDGEMENTS ! I would like to thank Dr. Behrents for giving me the

opportunity to continue my education in the specialty of orthodontics and for his constant guidance and encouragement during the past two and a half years. I would like to thank Dr. Araujo for his encouragement and guidance. I would like to thank Dr. Kim for his support and friendship. Thanks to Dr. Heidi Israel for her assistance with the statistical analysis. ! !

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TABLE OF CONTENTS List of Tablesvi List of Figuresx CHAPTER 1: CHAPTER 2: INTRODUCTION1 REVIEW OF THE LITERATURE4 Ideal Smile Esthetics4 Definition of a Gummy Smile5 Causes of a Gummy Smile Pre-Treatment8 Sex Predilection8 Musculature and Lip Incompetence8 Lip Length10 Altered Passive Eruption10 Skeletal Disharmonies13 Possible Causes of Gummy Smile Development During Orthodontic Treatment18 Unexpressed Vertical Growth18 Extrusive Forces20 Anterior-Posterior Position of the Maxilla21 Treatments For Gingival Smiles23 Treatments For Gingival Smiles Caused by Altered Passive Eruption23 Treatments For Gingival Smiles Caused by Incorrect Dental and Skeletal Relationships25 Orthodontic Intrusion25 Implant Intrusion26 Orthognathic Surgery28

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Treatments For Gingival Smiles Caused by Hyperfunction of the Lip Elevators29 Muscle Resection30 Botulinum Toxin31 Anterior Nasal Spine Implants34 Summary and Statement of Thesis35 References37 CHAPTER 3: JOURNAL ARTICLE

Abstract41 Introduction43 Materials and Methods46 Sample46 Sample Selection46 Data Collection51 Data Analysis57 Analysis of Error57 Results58 Discussion77 Design77 Findings78 Conclusions94 Appendix A96 Appendix B110 Literature Cited123 Vita Auctoris124

LIST OF TABLES Table 3.1: Table 3.2: Table 3.3: Table 3.4: Table 3.5: Table 3.6: Table 3.7: Descriptive Statistics for the Change in Gingival Display for the 200 subjects49 Description of Sample Groups50 Landmark abbreviations and descriptions51 Group 1 Pre-Treatment Vs. Post-Treatment Landmark Measures61 Group 2 Pre-Treatment Vs. Post-Treatment Landmark Measures63 Group 3 Pre-Treatment Vs. Post-Treatment Landmark Measures65 Descriptive Statistics for Significant Horizontal Soft Tissue Landmarks at the PostTreatment Time Point67 ANOVA for Significant Horizontal Soft Tissue Landmarks at the Post Treatment Time Point67 Tukey Post Hoc Multiple Comparisons Of Significant Horizontal Soft Tissue Landmarks at the Post Treatment Time Point68

Table 3.8: Table 3.9:

Table 3.10: Descriptive Statistics for the Significant Vertical Landmark at the Post Treatment Time Point69 Table 3.11: ANOVA for the Significant Vertical Measure at the Post Treatment Time Point69 Table 3.12: Tukeys Post Hoc Multiple Comparisons of the Significant Vertical Landmark at the Post Treatment Time Point69 Table 3.13: Comparison of Mandibular Horizontal Measures at T1 and T270 Table 3.14: Table 3.13 Comparison of Mandibular Vertical Measures at T1 and T271

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Table 3.15: Comparison of the Horizontal Maxillary Landmarks at T1 and T272 Table 3.16: Comparison of Vertical Maxillary Landmarks at T1 and T272 Table 3.17: Comparison of Horizontal Soft Tissue Landmarks at T1 and T273 Table 3.18: Comparison of Vertical Soft Tissue Landmarks at T1 and T274 Table 3.19: Comparison of Horizontal Dental Landmarks at T1 and T275 Table 3.20: Comparison of Vertical Dental Landmarks at T1 and T276 Table 3.21: Group Gender Percentages88 Table 3.22: Mean Lip Length at T189 Table 3.23: Mean Lip Length at T289 Table 3.24: Change in Mean Lip Length from T1 to T289 Table 3.25: Group Molar Classification90 Table 3.26: Molar Classification Percentages91 Table 3.27: Group Percentages of Class IIs91 Table 3.28: Class II Division Percentages92 Table A.1: Pre-Treatment Horizontal Mandibular Measures Descriptive Statistics96

Table A.2: ANOVA for Pre-Treatment Horizontal Mandibular Measures97 Table A.3: Pre-Treatment Vertical Mandibular Measures: Descriptive Statistics98 Table A.4: ANOVA for Pre-Treatment Vertical Mandibular Measures99

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Table A.5: Pretreatment Horizontal Maxillary Measures: Descriptive Statistics100 Table A.6: ANOVA for Pretreatment Horizontal Maxillary Measures100 Table A.7: Pretreatment Vertical Maxillary Measures: Descriptive Statistics101 Table A.8: ANOVA for Pretreatment Vertical Maxillary Measures101 Table A.9: Pretreatment Horizontal Dental Measures: Descriptive Statistics102 Table A.10: ANOVA for Pre-Treatment Horizontal Dental Measures103 Table A.11: Pretreatment Vertical Dental Measures: Descriptive Statistics104 Table A.12: ANOVA for Pretreatment Vertical Dental Measures105 Table A.13: Pretreatment Measures for Non-significant Horizontal Soft Tissue Landmarks: Descriptive Statistics106 Table A.14: ANOVA for Non-significant Pretreatment Horizontal Measures107 Table A.15: Pretreatment Vertical Measures for Soft Tissue Landmarks: Descriptive Statistics108 Table A.16: ANOVA for Pretreatment Vertical for Soft Tissue Landmarks109 Table B.1: Table B.2: Post-Treatment Non-Significant Horizontal Mandibular Measures: Descriptive Statistics.110 ANOVA for Post-Treatment Mandibular Horizontal Measures111

Table B.3: Post-Treatment Non-Significant Vertical Mandibular Measures: Descriptive Statistics112

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Table B.4: ANOVA for Non-Significant Post-Treatment Vertical Mandibular Measures113 Table B.5: Post-Treatment Horizontal Maxillary Measures: Descriptive Statistics114 Table B.6: ANOVA for Post-Treatment Horizontal Maxillary Measures114 Table B.7: Post Treatment Vertical Maxillary Measures: Descriptive Statistics115 Table B.8: ANOVA for Post-Treatment Vertical Maxillary Measures115 Table B.9: Non-Significant Post-Treatment Horizontal Soft Tissue Measures116 Table B.10: ANOVA for Non-Significant Post Treatment Horizontal Soft Tissue Measures116 Table B.11: Post-Treatment Vertical Soft Tissue Measures: Descriptive Statistics117 Table B.12: ANOVA for Post-treatment Vertical Measures for Soft Tissue Landmarks118 Table B.13: Post-treatment Horizontal Dental Measures: Descriptive Statistics119 Table B.14: ANOVA for Post-Treatment Horizontal Dental Measures120 Table B.15: Post-Treatment Vertical Dental Measures: Descriptive Statistics121 Table B.16: ANOVA for Post-Treatment Vertical Dental Measures122

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LIST OF FIGURES Figure 3.1: Figure 3.2: Figure 3.3: Figure 3.4: Figure 3.5: Figure 3.6: Calculation of Gingival Display47 Description of Measures of Gingival Display48 Cephalometric Landmarks53 Reference Planes55 Examples of Vertical and Horizontal Measures from the Reference Planes56 Graphical Representation of Changes from T1 to T2 for Group 181

Figure 3.7: Graphical Representation of Changes from T1 to T2 for Group 282 Figure 3.8: Graphical Representation of Changes from T1 to T2 for Group 383

INTRODUCTION ! ! As society becomes more esthetically conscious, orthodontists are more challenged to produce not only outstanding occlusions, but also outstanding esthetics. Every minute detail is becoming more important in separating the good from the great orthodontist. Recent

CHAPTER 1:

studies have indicated that the amount of gingival display on smiling is very important to smile attractiveness.1 In fact, Van der Geld et al. found that the amount of gingival display was an important characteristic in a persons own satisfaction with their smile.2 When an excessive amount of gingiva is displayed upon smiling, the term gummy is often used. While many clinicians anecdotally point to the lack of vertical control as the cause of orthodontically produced gumminess, few studies that investigate the cause of post treatment gummy smiles are present in the literature. et. al in 1992 found that the tendency of a person to project a gummy smile was related to anterior vertical maxillary excess, the muscular ability to raise the upper lip higher than average when smiling, greater overjet, greater interlabial gap at rest, and greater overbite.3 In his study to determine the effectiveness of improving Peck

patient smiles with orthodontic treatment and the variability of improvement from orthodontist to orthodontist, Mackley found that the orthodontist who was most successful in producing greater post treatment smile improvement scores decreased the stomion-incision measurement while those that increased the stomion-incision measure produced smiles with lower post treatment improvement scores. He states, This measurement is an

indication of the amount of gingival tissue that shows when a person is smiling. He also suggested that the most successful orthodontist also increased the inclination of the maxillary incisor to the NA line, while those that produced less improvement decreased this measure. He

concludes that in order to maximize our potential for improving the smile, we must include in our treatment plan an objective for moving the anterior teeth vertically to improve their relationship to the smiling lip line.4 While both of these studies indicate possible reasons for an increase in gingival display, neither indicates any pre-treatment skeletal or dental factors that might help a clinician to predict the tendency to develop this gumminess nor investigates post-treatment skeletal factors that might be associated with this negative condition. The purpose of this study is to determine which

dental, skeletal, and soft tissue characteristics effect smiling lip height and which characteristics affect lip height changes during treatment.

CHAPTER 2:

REVIEW OF THE LITERATURE

Ideal Smile Esthetics According to Hulsey, A smile is one of the most effective means by which people convey their emotions.5 People with dental deformities often make every effort to cover the displeasing portion with their lips. They rarely

smile or laugh, and thus might be viewed by others as unfriendly.6 This might not only affect a person in their personal life, but also professionally. According to Dale

Carnegie, one of the most important ways to win friends and influence people is to smile.7 In fact, according to Van der Geld et. al., studies have shown that higher intellectual and social abilities have been attributed to individuals with esthetic smiles.2 This is the reason that millions of people seek orthodontic treatment each year, to produce a smile they are pleased to view themselves and show to others. As society becomes more esthetically conscious, orthodontists are challenged to produce not only outstanding occlusions, but also outstanding esthetics. Every minute detail is becoming more important in separating the good from the great treatment. However, in order to create the best possible esthetics, orthodontists must understand what the public at large views as beauty. As Peck, Peck, and Kataja suggest, We orthodontists tend 4

to forget that facial esthetics is a subject that interests all people everywhere, and the ultimate source of esthetic values should be the people and not just ourselves.3 Within recent years, many researchers have directed their studies towards addressing this very question. In their study to determine the average desirable characteristics of an esthetic smile, Tjan et al. found that the average esthetic smile has the following characteristics: the full length of the maxillary anterior

teeth are displayed, the gingiva does not show, the incisal curvature of the maxillary anterior teeth parallels the inner curvature of the lower lip, the incisal curvature either touches or almost touches the lower lip, the six maxillary anterior teeth and the first or second premolars are displayed, and the midline coincides with the philthrum of the lip.8 Many other studies have confirmed these findings.1,4,7 Definition of a Gummy Smile Studies aimed at determining the characteristics of an ideal smile have all stressed the importance of the vertical placement of the maxillary incisors in relation to both the upper and lower lips in the production of the most esthetic smile. Van der Geld et al., found that the size of the teeth, visibility of the teeth, and upper lip position 5

are critical factors in self perception of smile attractiveness, as well as the color of the teeth and gingival display. In their study, participants with 2 to 4 mm of gingival display were judged most favorable,2 however the literature suggests varying threshold levels of gingival display are tolerated before the amount of gingival display negatively affects the perceived esthetics of a smile.9 Kokich et al., first reported that 4.0 millimeters (mm) of gingival display represents the threshold of acceptability, but more recently, using smaller increments of measure, found 3 mm of gingival display are considered unaesthetic by lay people.10 Chiche and Pinault found that up to 3 mm of gingival tissue may be displayed before esthetics is compromised.11 Geron and Atalia found that gingival exposure is considered an unaesthetic feature above 1 mm in the maxilla,12 and Hunt et al. found the acceptable range for gingival exposure to lie between 0 and 2 mm with an ideal of no gingival exposure.13 Ker et al. reported that while laypersons preferred 2.1 mm of incisor coverage, +- 4 mm was within the range of acceptiblity.1 In his study to determine whether the smiles of orthodontically treated patients are as esthetically pleasing as those of persons with normal occlusion,

Hulsey noted that the most attractive smiles were those in which the upper lip rested at the height of the gingival margin of the maxillary incisor.5 Perhaps the variation in preference for the amount of gingival display is due in part to a variation in the preference of gingival display between male and female subjects. In their study, Gul-e-

Erum found the ideal gingival display to be 0 mm for males and 2 mm for females.14 While the acceptable range of gingival exposure has been debated, it is apparent that an excess of 4 mm of gingival display on smiling is considered unaesthetic, and the majority of the literature supports 0-1 mm of gingival exposure as the ideal. For this reason, orthodontists

should pay special attention to the vertical placement of the maxillary anterior teeth during treatment planning and treatment. As Mackley asserts, If we are going to maximize our potential for improvement of the smile, we must include in our treatment plan an objective that will improve the relationship of maxillary incisors to the smiling lip line. To do less than this is to do our patients a disservice.4 When an excess of gingiva superior to the maxillary anterior teeth is displayed upon full smile, it is termed a gingival smile.3 The gingival smile is known by a variety of terms including gummy smile, high lip line, short upper 7

lip, and full denture smile.3 Perhaps this variety in terms is indicative of the many different causes of a gummy smile. Causes of a Gummy Smile Pre-Treatment Sex Predilection The tendency to have a gingival smile, appears to have a sex predilection. According to a study by Tjan, Miller,

and The, low smile lines are predominantly a male characteristic by 2.5 to 1, and high smile lines are predominantly a female characteristic by 2 to 1.8 Peck, Peck, and Kataja quantified these findings. They found

that at maximum smile, the upper lip line relative to the gingival margin of the maxillary central incisors is positioned 1.5 mm more superiorly in females than in males.15 Similarly, Vig and Brundo found that maxillary anterior tooth display was found almost twice as often in women as in men.16 A literature search by Van der Geld and Van Waas, further supports this assertion, indicating that on average, the smile line was situated higher among women than among men.17

Musculature and Lip Incompetence The musculature can also have an effect. Peck et al,

found that the upper lip in gingival smile subjects 8

elevates superiorly 1 mm more from rest to maximum smile than did a reference group.3 They also found that the interlabial gap at rest position was much higher on average (6.2mm) for the gingival smile line sample, than the reference sample (3.0 mm).3 This indicates that lip incompetence can be associated with a gingival smile line. Upon further investigation, they found that 93% of the gingival smile line group were lip incompetent at rest, while only 63% of the reference sample were lip incompetent at rest. When the likelihood ratio was calculated, it was

determined that the gingival smile line subjects were 5.5 times more likely to exhibit lip incompetence at rest than the reference population.3 In his descriptive essay, Matthews proposes that a person exhibiting an interlabial gap at rest will also have a gingival smile line,6 however while Peck et al. found that 93% of his gingival smile line subjects also exhibited an interlabial gap at rest, he also found that the opposite was not true. Only 56% of their

subjects with interlabial gaps at rest presented a gingival smile line. Therefore, while Peck et al.s study supports the assertion that an interlabial gap at rest is highly associated with the tendency to have a gingival smile line, it also indicates that an interlabial gap at rest cannot be considered predictive of the gingival smile phenomenon.3 9

Interestingly, Schendel et al. cite a large interlabial distance as a common characteristic of vertical maxillary excess, and these VME subjects also displayed an excessive amount of the maxillary teeth and gingiva upon smiling.18 These findings suggest that orthodontic techniques that cause lip incompetence, might also have a tendency to cause a gingival smile.

Lip Length While lip length has been suspect in producing a gingival smile line, Peck et al. found no difference in upper lip length between the gingival smile and reference groups, with both samples having a mean value of 22.3 mm.3 This is consistent with Schendel et al.s report that surgical patients with vertical maxillary excess have normal lip lengths.18 In fact, in a study of 70 gingival smile females, Singer found that the gingival smile group actually had a significantly longer lip length than the non-gingival smile sample.19

Altered Passive Eruption Short clinical crown heights have also been reported to increase the tendency to produce a gingival smile. clinical crown heights can be due to altered passive 10 Short

eruption, inflammation, and gingival enlargement. Active eruption is the movement of the tooth toward the occlusal plane. Passive eruption is the apical migration of the Therefore, altered passive eruption, is

gingival margin.

the delay in the apical migration of the epithelial attachment toward the root surface of at the CEJ. According to Waldrop, altered passive eruption can cause excessive gingival display.20 Garber and Salama agree stating, if the teeth appear to be somewhat short and squat-meaning that the vertical dimension appears to be too short as compared with the horizontal dimension, the gummy smile is probably due to altered passive eruption.21 However, in Pecks study, the clinical crown height of the two groups was not significantly different.3 As Garber and Salama point out, in many cases, a gummy smile may be due to a combination of vertical maxillary excess and altered passive eruption.21 Altered passive eruption can be classified into two distinct types. In Type I, there is an excessive amount of

gingiva from the free gingival margin to the mucogingival junction. In Type II, there is a normal amount of gingiva

as measured from the free gingival margin to the mucogingival junction. Type I is further subdivided into

sub-categories A and B depending on the relationship of the osseous crest to the cemento-enamel junction of the tooth. 11

In subcategory A, the dimension between the osseous crest and the CEJ is greater than 1 mm, and therefore adequate for the insertion of the connective tissue attachment component of the biologic width. In subcategory B, the osseous crest is in close proximity to the cementoenamel junction, therefore adequate space for the connective tissue attachment component of the biologic width is not present, and the connective tissue appears to attach at the same level as the cementoenamel junction. This seems

contrary to the biologic width, as the connective tissue attachment must be present, yet cannot attach to the enamel. According to Garber and Salama, clinical and

histological observations suggest that an increased buccolingual dimension of the osseous form allows for apical angulation of the bone crest from the gingival aspect of the periodontal ligament side.21 While periodontal connective tissue fibers normally run horizontally across the osseous crest extending from the cementum to the gingival, in this form of altered passive eruption, the fibers run apically, parallel to this angular crest, allowing the connective tissue fibers to insert into the cementum just apical to the cementoenamel junction. The biologic width is approximately 2.7 mm in dimension.19,20 and is made up of 1 mm of junctional 12

epithelium, 1 mm of connective tissue attachment, and 1 mm of sulcus depth.21 This biologic width is necessary for the health of the periodontium and should not be violated with restorative procedures. Due to its association with

this biologic parameter, the type and subcategory of altered passive eruption present will determine the treatment modality.21 In a study of 1025 patients, Volchansky et al. found altered passive eruption in 12% of the patients.22 However, more recently, Konikoff et al. found that 65% of post orthodontic patients had less than ideal length to width ratios in their anterior incisors.23 Therefore, after thorough oral hygiene instruction, scaling and root planning as needed, and a period of inflammation control, patients with excessive gingival display should be evaluated for altered passive eruption and the need for a periodontal procedure.20

Skeletal Disharmonies Growth of the maxilla is also related to gingival smiles. According to Wilmar, the gingival smile line is often associated with maxillary alveolar overdevelopment or vertical maxillary excess (VME).24 Peck et al.s study supports this. They found that the anterior maxillary 13

height (measured from the palatal plane to the upper incisor edge) showed a significant difference between the gingival smile group and the reference group with a difference of +2.3 mm (p <.001).3 In their study of individuals with vertical maxillary excess, Schendel et al. found that all persons in their VME sample, both with open bite and without, showed excessive exposure of the maxillary anterior teeth and poor upper lip to tooth relationships in comparison to the norm.18 According to Schendel et al., extreme clockwise rotation, high angle type, adenoid faces, idiopathic long face, total maxillary alveolar hyperplasia, and vertical maxillary excess all have excessive vertical growth of the maxilla as their common denominator.18 While many children and adults with long faces also have vertical maxillary excess, Fields et al. found that long faced children did not have a significantly greater anterior dental height than normal children, and while the adults had a tendency for excessive eruption of all teeth, it was not statistically significant.25 However, patients with long faces do have some characteristic traits, such as increased mandibular plane angles, increased palatal plane to mandibular plane angles, increased ANB angles (and thus retrognathia), and increased lower anterior face heights. 14 Therefore, one

might conclude that persons with these characteristics might also have the tendency for excessive gingival display, although not to a predictive level. In a study by

McNamara et al, neither the vertical display on smile, nor the amount of upper lip drape was correlated with the skeletal vertical dimension,26 therefore it appears that vertical maxillary excess is only one contributing factor to a gummy smile. In Schendel et al.s study, the differences between long faced, open bite and non open bite subjects were investigated.18 They found that the open bite group had a steeper mandibular plane angle, although both the open bite and non open bite groups mandibular plane angles were significantly greater than the norm. angle followed the same trend. The occlusal plane

The SNA was normal in both

groups, suggesting a normal anteroposterior position of the maxilla in relation to the cranial base. However the SNB

was significantly decreased in both groups suggesting a retrodisplacement of the mandible. Due to this

displacement, the ANB angle was also significantly increased in both groups. Both the posterior height of the maxilla and the anterior dental height were significantly greater than normal. The largest vertical distance between the two groups was the posterior facial height. 15 The open

bite group had a normal ramal length while the non open bite group exhibited a long ramal length.18 This suggests that there was greater vertical growth of the ascending ramus in the non open bite group that prevented the development of an open bite. While Schendel and colleagues

found both groups to exhibit an increased amount of maxillary display, it seems evident that orthodontic treatment aimed to close the open bite via anterior extrusion with or without posterior intrusion, would exacerbate this problem. The influence of skeletal disharmonies on the production of a gingival smile line has been debated in the literature. Singer cites SN-MP and SN-Pal as having characteristic values associated with a gingival smile line,19 however in Peck et al.s study, the SN-MP and SN-PP angles were not significantly different between the gingival smile and reference groups.3 The study by Schendel et al. would refute this finding, as they described all of the VME sample to possess both an excess of gingival display on smiling, and high mandibular plane angles as well as an increased posterior height of the maxilla.18 A study by Fields et al. compared the differences in long faced children and adults as compared to normal and short faced children and adults. 16 They found that long

faced, short faced, and normal children all have a similar relationship of the maxilla to the cranial base. The long

and short-faced children had a tendency for a smaller SNB angles, and therefore more retrognathic profiles than normal children. The long-faced children had steep

mandibular plane angles while the short-faced children displayed low mandibular plane angles. Measures of the

total anterior facial height were significantly different between the groups, however there were no differences evident in posterior total facial height. The differences

in the anterior facial height were found to lie within the anterior lower face height, as the measures of the anterior upper facial height were similar among the groups. further examination to determine the cause of this difference, they found no difference in the size of the ramus, but the gonial angles were significantly larger in long-faced children and smaller in short-faced children. Long-faced children had significantly greater posterior maxillary and mandibular dental heights than normal children. However, surprisingly there was not a significant difference in the anterior upper dental height, although the mean height was larger in the long faced children. As Upon

would be expected, short faced children had significantly

17

less anterior upper and lower dental height than normal children.25 Similar results were found for the adult groups with a few important differences. Like the children, all groups

had similar cranial base configurations with well-related maxillas, the long faced adults tended to be more retrognathic, and the mandibular plane angles indicated significant differences. The posterior total facial

heights and the anterior upper face heights were similar for the groups, and the long faced adults had significantly increased lower anterior facial heights. Similar to the

children, the long faced adults had normal mandibular body lengths and increased gonial angles, but unlike the children they had a tendency toward short rami and excessive eruption of all teeth.25

Possible Causes of Gummy Smile Development During Orthodontic Treatment Unexpressed Vertical Growth As Fields and colleagues asserts, it is possible that ramus differences are not apparent in children, since rapid skeletal growth, and therefore, significant ramus lengthening had not yet occurred in the preadolescent sample.25 This might indicate a cause for the skeletal 18

tendency to become gummy during the course of orthodontic treatment. Because orthodontic treatment is often commenced during early adolescence, the growth that occurs in long faced individuals during this time (between childhood and adulthood) appears to convert children with normal ramus lengths and normal anterior dental heights to adults with short mandibular ramus lengths and a tendency toward long anterior dental heights. This decreased amount of growth of the ramus, appears to affect the mandibular rotation, and therefore produces a steeper mandibular plane angle.27 Schendel et. al. found short ramus heights in long faced individuals with open bites, but long ramus heights in long faced patients without open bites compared to the norm. Those with short ramus heights and open bites also had much much higher mandibular plane angles (SN-MP) on average (48.61 degrees) than the non-open bite, long-faced individuals with long ramal lengths (39.78 degrees). However, both long faced groups had much greater mandibular plane angles than the norm (31.75 degrees).18 This finding agrees with the finding of Isaacson et al. who found shorter ramus heights to be characteristic of patients with steep mandibular plane angles.27 This lengthening in anterior dental heights (or vertical maxillary excess) that appears to occur as long19

faced children grow into adulthood, would likely increase the gingival display in these patients during growth even without orthodontic treatment (as previously discussed).

Extrusive Forces The tendency to develop a gingival smile might be improved with careful orthodontic manipulation, however it could easily be exacerbated if not diligently monitored, as many of the forces used in orthodontic treatment are extrusive. As Fields et al. points out, although these

facial patterns are established early, events may occur during adolescence to magnify or maintain the differences.25 Because the full effect of this growth pattern is not yet evident during childhood, the prudent orthodontist will recognize this pattern during diagnosis of young patients, and discuss its tendency to produce excessive gingival display with the patient and parents. He/she should also include in his/her treatment steps to control and not exacerbate this tendency. In Isaacson et al.s study of the extreme variations in vertical facial growth, they state that the vertical growth of the anterior face must be equal in size and timing of the growth increases in the posterior face, or the mandible will rotate at its articulation.27 20 According

to Isaacson et al., if the vertical increases at the facial sutures and/or the alveolar process should exceed the vertical increases at the mandibular condyle, the mandible would rotate backward. Conversely, if vertical

growth at the condyle should exceed the sum of the vertical growth components at the facial sutures and alveolar processes, the mandible would rotate forward.27 According

to this study, if extrusive orthodontic forces cause vertical growth of the alveolus faster than the condyle is growing vertically, then the mandible could rotate backward even in a patient without previous vertical growth.

Anterior-Posterior Position of the Maxilla In their study, Isaacson et al. also found that as the mandibular plane angle (SN-MP)decreased, the mean values for SNA and SNB increased.27 The mean ANB angle remained relatively constant. The measurements of linear

distance from a perpendicular to SN to the maxillary first molar indicated that not only the skeletal components increased in the horizontal dimension as the mandibular plane angle decreased, but the dental components also became more anteriorly situated.27 Therefore, Isaacson concluded that the horizontal position of the maxilla effects the mandibular plane angle. 21 For this reason, a

person with a forward positioned maxilla and some vertical maxillary excess could have a low mandibular plane angle, and therefore, unless specifically measured, the maxillary excess could perhaps be unapparent upon initial examination. Persons presenting with a forward positioned

maxilla whether high or low angle, often have a Class II skeletal and dental pattern. Orthodontic treatment aimed

at distalizing the maxilla, or maxillary dentition, to correct the Class II dentition, according to Isaacsons study, would cause downward rotation of the mandible and an increase in the mandibular plane angle, and would therefore allow room for further increase in the height of the maxilla both posteriorly and anteriorly. According to

Schendel and Fields studies, this could cause an increased tendency for gingival display.18,25 However, the literature tends to refute this point. In Pecks study, the gingival smile line group had greater values for both overbite and overjet, by 1.5 mm and 1.0 mm respectively.3 Therefore, it would seem that correcting the overjet, might decrease the gingival smile. Accordingly, Vig and Brundo found that individuals with moderate to severe Class II malocclusions demonstrated an exceptional resistance to the normal pattern of decreased maxillary incisor show with age.16 Peck et al. suggest that 22

orthodontic correction of overjet may then improve a gingival smile line in a Class II condition.3

Treatments For Gingival Smiles As with any other orthodontic problem, the appropriate treatment for a gingival smile is determined by the cause. A gingival smile caused by short clinical crowns should be treated with the appropriate gingival procedure, while a gingival smile due to incorrect dental and skeletal relationships should be treated orthodontically, or with a combination of orthodontics and surgery. Other less

invasive procedures are also emerging to camouflage a skeletal problem such as botox injections to decrease the mobility of the upper lip and even anterior nasal spine implants.

Treatments for Gingival Smiles Caused by Altered Passive Eruption As previously discussed, altered passive eruption ia classified into two types, and the appropriate treatment is determined by the type present. In Type I, there is an

excessive amount of gingiva from the free gingival margin to the mucogingival junction. In Type II, there is a

normal amount of gingiva as measured from the free gingival

23

margin to the mucogingival junction.

Type I is further

subdivided into sub-categories A and B depending on the relationship of the osseous crest to the cemento-enamel junction of the tooth. In subcategory A, the dimension

between the osseous crest and the CEJ is greater than 1 mm, and therefore adequate for the insertion of the connective tissue attachment component of the biologic width. In subcategory B, the osseous crest is in close proximity to the cementoenamel junction, therefore adequate space for the connective tissue attachment component of the biologic width. Because there is adequate room for the connective tissue attachment in Type IA, a simple gingivectemy procedure can be performed to remove the excess gingiva. However,

because there is not adequate space for the connective tissue attachment in Type IB, the connective tissue is attached to the enamel. Therefore, without moving the

crestal bone apical to the cementoenamel junction to allow adequate space for the connective tissue attachment to form in its proper location, the connective tissue attachment will reform on the enamel, and the gingival margin will rebound. For this reason, gingivectemy procedures will be

unsuccessful, and a crown lengthening procedure to move the

24

crestal bone apically will be necessary to provide stable results.20,21 In Type II altered passive eruption, the zone of masticatory mucosa is not excessive, despite the clinically evident short teeth. Treatment requires apical reduction

of the entire dentogingival complex with or without osseous reduction to provide more ideal esthetics.20

Treatments for Gingival Smiles Caused by Incorrect Dental and Skeletal Relationships According to Proffit et al. There are now three possible approaches to excessive gingival exposure due to incorrect dental and skeletal relationships: orthodontic intrusion,

orthognathic surgery to move the maxilla up, and implant anchorage to intrude the maxillary teeth.28 The appropriate treatment is determined by the etiology of the problem and the age of the patient. Orthodontic Intrusion If the maxillary anterior teeth are excessively extruded in relation to the posterior teeth and the bite is deep, then the anterior teeth can be orthodontically intruded. According to Garber and Salama, the entire attachment apparatus, incorporating the bone, periodontal ligaments, and the soft tissue moves together with the tooth,21 and 25

therefore intrusion should improve a gingival smile. However, according to Waldrop, the ability of the orthodontist to change gingival margin locations with tooth movement may be affected by the facial-lingual thickness of the attached gingival and bone.20 If the gingival smile is due to a true skeletal Vertical Maxillary Excess (VME), then the posterior portion of the maxilla will also be vertically overexpressed, causing the mandible to rotate downward and backward. In children, this growth pattern could possibly be modified with careful attention to prevent all subsequent posterior vertical growth of the maxilla, thus allowing the mandible to rotate upward and forward if there is adequate vertical ramus growth.29 This can be achieved with various approaches including high-pull headgear to the maxillary molars, highpull headgear to a maxillary splint, a functional appliance with bite blocks, and even a high-pull headgear to a functional appliance with bite blocks for the the most severe cases.29 Implant Intrusion Until recently, intrusion of the maxillary anterior teeth without the side effects of posterior extrusion was very difficult. Extraoral force applications using the head as

anchorage (i.e., headgear) was the method of choice to 26

either directly intrude the anterior teeth (i.e., J-Hook headgear), or to prevent the side effects of an anterior intrusion arch (i.e. high pull headgear). However, the

unesthetic appearance of headgear decreased patient compliance with full time wear and therefore decreased its effectiveness. With the advent of orthodontic implants, also known as temporary anchorage devices, effective intrusion of anterior teeth has become possible. In a recent study by Deguchi et. al., the effects of intrusion of the maxillary incisors via implants was compared to the effects produced with a J-Hook headgear. They found that

while both groups experienced significant reductions in overjet, overbite, and maxillary incisor to upper lip, there were significantly greater reductions in overbite, maxillary incisor to palatal plane, and maxillary incisor to upper lip in the implant group. A force analysis

indicated that the implant intrusion produced a significantly greater force in the vertical direction and less in the horizontal direction than the J-hook headgear group.30 This study indicates that implant intrusion might achieve more true intrusion without the undesired tipping of the maxillary incisors that often occurs with traditional intrusion mechanics. In a recent study by They

Polat-Ozsoy et.al., similar findings were reported.

27

found a mean intrusion of 2.25 mm with only small and insignificant changes in the U1 to NA and U1 to Palatal plane angles, 1.22 and 1.81 mm respectively.31 Not only do orthodontic implants appear to achieve more true intrusion without the undesired side effects, but according to a study by Scheffler at the University of North Carolina in 2005 (cited by Proffit et. al.) patients prefer implants to headgear and reported minimal pain from implant placement.28 Other recent case reports have also demonstrated successful treatment of patients with deep overbites and gummy smiles with the use of orthodontic implants for maxillary incisor intrusion.32,33 Orthognathic Surgery In adults, growth modification is no longer an option. Therefore, intrusion of the anterior teeth in the absence of a deep bite would, at the very least, create a reverse smile arc, and possibly result in an anterior open bite. Therefore, orthognathic surgery to impact the maxilla is the only true corrective treatment option. However, as

Garber et. al. points out, proper diagnosis of the severity of the vertical maxillary excess present involves ruling out the superimposition of altered passive eruption in combination with maxillary hyperplasia. They state, if

altered passive eruption is present, it should be treated 28

first to develop a normal tooth form before a final treatment plan is determined.21 Only then can the true severity of the hyperplasia be assessed. In some cases, the translation of the upper lip from rest to maximum smile is greater the normal length of a tooth crown. In such a

case, the patient must determine if some gingival display will be tolerated, or if a increased length of the crowns of the maxillary incisors is preferred. This will prevent overimpaction of the maxilla, which results in burying of the incisal edge beyond the vermillion border of the lip resulting in a dramatically aged appearance. For this

reason, it is critical to treat to the position of the lip at rest. A minimum of 2 mm of the incisal edge of the

maxillary incisors should be displayed at rest.21 Peck points to surgical repositioning of the maxilla to reduce vertical maxillary excess as the most effective treatment modality. However, he notes that this procedure has

limitations due to the lip shortening that occurs with skeletal intrusion (50% of the skeletal intrusion).3

Treatments for Gingival Smiles Caused by Hyperfunction of the Lip Elevator Muscles Due to the invasiveness and cost of maxillary osteotomy surgery, other methods of correcting a gummy 29

smile have emerged. In Peck et al.s study, the gingival smile group raised the upper lip higher than average during smiling.3 This hyperfunction of the lip elevator muscles is thought to contribute to the production of a gummy smile. Therefore, several soft tissue surgical procedures have been reported to correct a gummy smile caused by hyperfunction. These methods include severing the muscular

attachments, botulinum toxin, and even an anterior nasal spine implant. Muscle Resection Polo, Rubinstein and Kostianovsky describe a procedure in which a portion of the gingival and buccal mucosa is resected and the borders approximated and sutured.34 Litton and Fournier describe a procedure to detach the elevator muscles from the maxilla,35 while Miskinyar describes a technique in which he performs a myectomy and partial amputation of the levator labii superioris muscles.36 However, Ellenbogen reports that resection of the levator labii superioris is short lived, and the gummy smile returns within six months.37 He suggests placing either a nasal cartilage or prosthetic material as a spacer to prevent this reunion of the muscle fibers and reoccurrence of the gummy smile.37 Miskinyar reported good results with

this technique at 8 year follow ups, but points out 30

possible disadvantages including migration of the spacer to a foreign site, foreign body reaction if a prosthetic implant is used, and the need for a second surgical procedure if nasal cartilage is used.38 Rees and LaTrenta describe a camouflage procedure for long faced syndrome patients in which subperiosteal dissection of the lip elevators is performed,39 and Ezquerra et al. describe a multidisciplinary approach that incorporates lefort osteotomies, with gingival remodeling, and the procedure described by Rees and LaTrenta.40 Botulinum Toxin Although less invasive than an osteotomy, surgical procedures to resect the lip elevator muscles require incisions with the possibility of scarring and variable long-term results. Therefore, botulinum toxin has been

investigated as a non-surgical alternative for reducing gingival display caused by muscular hyperfunction. In a

recent study by Mario Polo,41 twelve women with excessive gingival display were injected at two sites with 1.25 U of botulinum toxin in the right and left levator labii superioris alaeque nasi muscles, and the overlap areas of the levator labii superioris and zygomaticus minor muscles. These injection were repeated in a second phase of the study one month later and followed by a 2.5 U injection in 31

a third phase.

Those that had the greatest amount of

elevation near the philthrum also received injections at the origin of the depressor septi nasi muscle at the orbicularis oris muscle at each phase of the study. He

found that all patients demonstrated improvement 10 days post-injection, while the maximum effect was observed 14 days post-injection with a mean decrease in gingival display of 4.2 mm. 3 to 6 months. This effect was reversible, lasting for

He reports that all patients were pleased

with the results and no side effects were reported or observed.41 In a letter to the editor in response to Polos article, Niamtu, relates experiences of unesthetic perioral animation in his patients treated with botulium toxin injections. He states, they looked dysfunctional,

described a range from slight change in smile, pucker, and word pronunciation to a stroke like expression in some phases of animation. He suggests that the photos in

Polos study cannot truly display the appearance of the patients in animation. While he relates years of

experience with botox, he warns that dramatic undesirable results can be produced by inexperienced practitioners including severe drooling, inability to pucker, grossly asymmetric smiles, inability to annunciate words, and a stroke like appearance.42 32

In a follow up study by Polo to determine whether the dose and injection sites used in the pilot study produce consistent, esthetically pleasing results, Polo injected 30 patients with 2.5 U at the same sites as discussed in his pilot study and followed them at 2,4,8,12,16,20 and 24 weeks post-injection with changes documented by photographs and videos. Again the maximum effect was observed at 2

weeks post-injection with a mean decrease in gingival display of 5.1 mm. The gingival display increased

gradually, although the gingival display had not yet returned to baseline by week 24. It was estimated with a

polynomial equation that the pre-treatment gingival display would not be reached until 30 to 32 weeks post-injection. At week 2, patients and a panel of specialty evaluators rated the effects of the botox injections via pre and post treatment photographs and videos on a 1 to 5 point scale with 1 representing poor and 5 representing excellent. Both patients and specialists rated the results between very good and excellent with a mean of 4.66 and 4.65 respectively.43 In a recent study by Hwang et. al., the distribution, morphology, and direction of muscles fibers of the levator labi superioris (LLS), the levator labii superioris alaeque nasi (LLSAN), and the zygomaticus minor (ZMi)and major(ZMj) muscles were investigated on 25 adult

33

cadavers with the aim of proposing a safe and reproducible injection point for botulinum toxin type A. They found

that the three lip elevator muscles converged on the area lateral to the ala of the nose with no significant differences in the angular projection of the muscle fibers from origin to insertion between males and females or left side to right side. This area of convergence was prosposed

as a safe and reproducible injection site for the botulinum toxin. Injection at this site was demonstrated to be

clinically effective in the reduction of a gingival smile due to muscular hyperfunction in two cases. In summary,

while still in its early stages, research indicates that botulium toxin type A might be an effective, yet transient treatment for excessive gingival display. Anterior Nasal Spine Implants In addition to surgical resection of the elevator muscles and botulinium toxin to reduce the activity of the muscles, the use of an anterior nasal spine implant has been reported to mechanically obstruct the lip from raising and thus reduce the amount of gingiva displayed upon smiling. Austin describes a technique in which a pouch is created by elevating the periosteum from the anterior nasal spine and adjacent maxilla for 10 mm on each side. It is then filled

with a silicone implant material, which is allowed to

34

harden and conform to shape of the area.

It is then

removed, trimmed to prevent protuberant edges and then reimplanted into the pouch and the pocket is sutured. He

reports excellent results and pleased patients with a mean follow up of three years. He reports only one infection

requiring removal of the implant and suggests both IV and local antibiotics to prevent this complication.44

Summary and Statement of Thesis The literature indicates that the ideal smile as determined by the general public displays very little gingiva upon smiling, and due to the increasing esthetic demands of the public, orthodontists are taxed to produce the ideal. Therefore, not only is the knowledge to treat

patients that present with gummy smiles necessary, but more important is the knowledge to recognize those that have a tendency to become gummy, and to prevent the development of a gummy smile during orthodontic treatment. The purpose of this study is to compare the pre and post treatment cephalometric radiographs of patients who obtain a great increase in gingival display during treatment to those that obtain a great decrease, as well as those that obtain the average change in gingival display.

35

It is our hope that this comparison will identify the pretreatment skeletal, dental, and soft tissue characteristics that indicate a tendency to obtain an increase or decrease in gingival display during treatment and/or the skeletal, dental, and soft tissue changes that occur to produce this change in lip drape.

36

References

1. Ker AJ, Chan R, Fields HW, Beck M, Rosenstiel S. Esthetics and smile characteristics from the layperson's perspective: a computer-based survey study. J Am Dent Assoc. 2008;139(10):1318-1327. 2. Van der Geld P, Oosterveld P, Van Heck G, KuijpersJagtman AM. Smile attractiveness. Self-perception and influence on personality. Angle Orthod. 2007;77(5):759765. 3. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992;62(2):91-100. 4. Mackley RJ. An Evaluation of smiles before and after orthodontic treatment. Angle Orthod. 1993;63(3): 183-189. 5. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod. Dentofacial Orthop. 1970;57(2):132-144. 6. Matthews TG. The anatomy of a smile. J Prosthet Dent. 1978;39(2):128-134. 7. Carnegie D. How To Win Friends and Influence People.. Simon and Schuster; 1936. 8. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):24-28. 9. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992;62(2):91-100; discussion 101-102. 10. Kokich VO, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-324. 11. Chiche GJ, Pinault A. Smile rejuvenation: a methodic approach. Pract Periodontics Aesthet Dent. 1993;5(3):37-44; quiz 44.

37

12. Geron S, Atalia W. Influence of sex on the perception of oral and smile esthetics with different gingival display and incisal plane inclination. Angle Orthod. 2005;75(5):778-784. 13. Hunt O, Johnston C, Hepper P, Burden D, Stevenson M. The influence of maxillary gingival exposure on dental attractiveness ratings. Eur J Orthod. 2002;24(2):199204. 14. Gul-e-Erum, Fida M. Changes in smile parameters as perceived by orthodontists, dentists, artists, and laypeople. World J Orthod. 2008;9(2):132-140. 15. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod. Dentofacial Orthop. 1992;101(6):519-524. 16. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39(5):502-504. 17. Van der Geld PA, van Waas MA. [The smile line, a literature search]. Ned Tijdschr Tandheelkd. 2003;110(9):350-354. 18. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ. The long face syndrome: vertical maxillary excess. Am J Orthod. Dentofacial Orthop. 1976;70(4):398-408. 19. Singer R. A study of the morphologic, treatment and esthetic aspects of gingival display. Am J Orthod. Dentofacial Orthop. 1974;65:435-436. 20. Waldrop TC. Gummy Smiles: The Challenge of Gingival Excess: Prevalence and Guidelines for Clinical Management. Seminars in Orthodontics. 2008;14(4):260271. 21. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol. 2000. 1996;11:18-28. 22. Volchansky A, Cleaton-Jones P. Delayed passive eruption-a predisposing factor to Vincent's infection. J Dent Assoc S Afr. 1974;29:291-294.

38

23. Konikoff BM, Johnson DC, Schenkein HA, Kwatra N, Waldrop TC. Clinical crown length of the maxillary anterior teeth preorthodontics and postorthodontics. J. Periodontol. 2007;78(4):645-653. 24. Willmar K. On Le Fort I osteotomy; A follow-up study of 106 operated patients with maxillo-facial deformity. Scand J Plast Reconstr Surg. 1974;12(0):suppl 12:1-68. 25. Fields HW, Proffit WR, Nixon WL, Phillips C, Stanek E. Facial pattern differences in long-faced children and adults. Am J Orthod. 1984;85(3):217-223. 26. McNamara L, McNamara JA, Ackerman MB, Baccetti T. Hardand soft-tissue contributions to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop. 2008;133(4):491-499. 27. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation in vertical facial growth and associated variation in skeletal and dental relations. Angle Orthod. 1971;41(3):219-229. 28. Proffit WR, Fields HW, Sarver DM. Chapter 8: Orthodontic Treatment Planning: Limitations, controversies, and Special Problems. In: Contemporary Orthodontics. fourth. St. Louis, Missouri: Mosby, Inc.; 2007. 29. Fields HW, Proffit WR. Chapter 13: Treatment of Skeletal Problems in Children. In: Contemporary Orthodontics. fourth. St. Louis, Missouri: Mosby, Inc.; 2007. 30. Deguchi T, Murakami T, Kuroda S, et al. Comparison of the intrusion effects on the maxillary incisors between implant anchorage and J-hook headgear. Am J Orthod Dentofacial Orthop. 2008;133(5):654-660. 31. Polat-Ozsoy O, Arman-Ozcirpici A, Veziroglu F. Miniscrews for upper incisor intrusion. Eur J Orthod. 2009;31(4):412-416. 32. Ohnishi H, Yagi T, Yasuda Y, Takada K. A mini-implant for orthodontic anchorage in a deep overbite case. Angle Orthod. 2005;75(3):444-452.

39

33. Kim T, Kim H, Lee S. Correction of deep overbite and gummy smile by using a mini-implant with a segmented wire in a growing Class II Division 2 patient. Am J Orthod Dentofacial Orthop. 2006;130(5):676-685. 34. Rubinstein A, Kostianovsky A. Cosmetic surgery for the malformation of the laugh: original technique. Prensa Med Argent. (60):952. 35. Litton C, Fournier P. Simple surgical correction of the gummy smile. Plast. Reconstr. Surg. 1979;63(3):372-373. 36. Miskinyar SA. A new method for correcting a gummy smile. Plast. Reconstr. Surg. 1983;72(3):397-400. 37. Ellenbogen R. Correspondence and brief communications. Plast. Reconstr. Surg. (73):697-98. 38. Miskinyar S. Correspondence and brief communications. Plast. Reconstr. Surg. (73):697. 39. Rees T, LaTrenta G. The long face syndrome and rhinoplasty. Persp Plast Surg. (3):116. 40. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast. Reconstr. Surg. 1999;104(4):1143-1150; discussion 1151-1152. 41. Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop. 2005;127(2):214-218; quiz 261. 42. Niamtu III J. Letters to the editor: Botox injections for gummy smiles. Am J Orthod Dentofacial Orthop. 2008;133:782-3. 43. Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop. 2008;133(2):195-203. 44. Austin HW. Correction of the gummy smile--a plastic surgeon's view. Dent Today. 1990;9(2):28.

40

CHAPTER 3:

JOURNAL ARTICLE

Abstract Objective: The purpose of this study is to determine

which dental, skeletal, and soft tissue characteristics affect lip height and which characteristics affect lip height changes during treatment. Materials and Methods:

Models for 200 randomly selected subjects were obtained and used to calibrate the smiling photographs of each subject. The photographs were then measured to determine the change in gingival display that occurred during treatment. The change in gingival display was used to create three groups: those that obtained the greatest increase, greatest decrease, and average change in gingival display. The cephalometric radiographs were then traced for each subject and digitized. The pre and post treatment cephalometric radiographs of each subject were superimposed and a total of 54 linear measures were made at each time point. The measures were then compared using t-tests for intra-group changes from T1 to T2 and an Analysis of Variance (ANOVA) for inter-group comparisons at each time point. Results: There were no significant differences between the Paired t tests

groups at the pretreatment time point.

revealed significant differences in 25 of the 27 vertical

41

measures within all groups from the pre treatment to posttreatment time points. The horizontal measures indicated

more significant differences in the backward direction in the greatest increase group than the other two groups. The significant vertical difference between the groups at the post-treatment time point was found between the average change group and the greatest increase group at condylion. The significant horizontal differences between the groups were found between the greatest increase and greatest decrease groups at the soft tissue lips. The lips moved

significantly backward in the greatest increase group while they stayed relatively the same in the greatest decrease group. Conclusions: No pretreatment characteristic could be

identified to predict the tendency to experience an increase or decrease in gingival display during orthodontic treatment. The lips moved significantly backward in the

group that experienced an increase in gingival display while they stayed relatively the same in the group that experienced a decrease. Although not significant, other general tendencies were apparent between the two extreme groups. Further research is warranted.

42

Introduction ! ! As society becomes more esthetically conscious, orthodontists are becoming challenged to produce not only outstanding occlusions, but also outstanding esthetics. Every minute detail is becoming more important in separating the good from the great treatment result. Recent studies have indicated that the public at large believes that the amount of gingival display on smiling is very important to attractiveness.1 In fact, Van der Geld et al. found that the amount of gingival display is an important characteristic in a persons own satisfaction with their smile.2 When an excessive amount of gingiva is displayed upon smiling, the term gummy is often used. While many clinicians anecdotally point to the lack of vertical control as the cause of orthodontically produced gumminess, few studies that investigate the cause of post treatment gummy smiles are present in the literature. et al. found that the tendency of a person to project a gummy smile was related to anterior vertical maxillary excess, the muscular ability to raise the upper lip higher than average when smiling, greater overjet, greater interlabial gap at rest, and greater overbite.3 This study, Peck

43

as well as many others, have found that females have a predilection to display more gingiva while smiling than their male counterparts.3456 Lip length has also been suspect to affect gingival display, however, the literature refutes this assertion.3,7 In fact, Singer reported that his gingival smile group had a significantly longer lip length than his non-gingival display group.8 Altered passive eruption has also been suggested to produce short clinical crown heights and therefore increase the tendency to produce a gingival smile. However, in Peck et al.s study, the clinical crown

height of the gingival display group was not significantly different.3 In Mackleys study to determine the effectiveness of improving patient smiles with orthodontic treatment and the variability of improvement from orthodontist to orthodontist, he found that the orthodontist who was most successful in producing greater post treatment smile improvement scores decreased the stomion-incision measurement, while those that increased the stomionincision measure produced smiles with lower post treatment improvement scores. He states, This measurement is an

indication of the amount of gingival tissue that shows when a person is smiling. He also suggested that the most 44

successful orthodontist also increased the inclination of the maxillary incisor to the Nasion-A Point line, while those that produced less improvement decreased this measure. He concludes that in order to maximize our

potential for improving the smile, we must include in our treatment plan an objective for moving the anterior teeth vertically to improve their relationship to the smiling lip line.9 While these studies indicate possible reasons for an increase in gingival display, none indicate any pretreatment skeletal or dental factors that might help a clinician to predict the development of this gumminess during orthodontic treatment nor investigates posttreatment skeletal and soft tissue factors that might produce this negative condition. The purpose of this study is to determine which dental, skeletal, and soft tissue characteristics affect smiling lip height and which characteristics affect lip height changes during orthodontic treatment.

45

Materials and Methods Sample A sample of 200 subjects (114 Females and 86 Males) was randomly selected from the archives of records at Saint Louis University Center for Advanced Dental Education. Only patients who began treatment between the ages of 10 and 14 years of age, and had pre and post treatment photographs, models, and lateral cephalometric radiographs were included. A consistent head position and extent of

smile in the pre and post-treatment photos were also required in order to be included in the study.

Sample Selection The database of records at the Center for Advanced Dental Education at Saint Louis University was reviewed beginning with the first letter of the alphabet. The first 200 patients that met the inclusion criteria were included in the study. Once the records were obtained, the width of

the maxillary left central incisor was measured to the nearest tenth of a millimeter using a digital caliper on the stone model and recorded. This measure was then used

to calibrate the smiling photograph of the patient using the Dolphin Imaging photo calibration tool. Once photo

calibration was completed, the length of the maxillary left

46

central incisor was measured on the stone model and recorded. For this purpose, the length of the maxillary left central incisor was defined as the distance between the incisal edge and the most superior point on the gingival margin. The distance between the incisal edge of the maxillary left central incisor and the most incisal portion of the upper lip was then recorded. The amount of

gingival display was recorded as the difference between the length of the maxillary left central incisor and the distance between the maxillary left central incisal edge and the most inferior portion of the upper lip (Figure 3.1). Therefore, patients with visible gingival exposure

upon smiling would have a positive number of gingival display and patients with lip coverage of their maxillary incisors upon smiling would have a negative number recorded (Figure 3.2).

Figure 3.1 Calculation of Gingival Display. The gingival exposure was calculated as the difference between 1 and 2 minus the difference between 1 and 3. i.e. (1-2)-(1-3). (Modified from Van der Geld et. al.) 2

47

Figure 3.2 Description of Measures of Gingival Display. A positive measure was given for any gingiva

visible above the maxillary left central incisor while any incisor coverage was given a negative measure (Modified from Peck and Peck)3 After the amount of gingiva displayed upon smiling was determined for the pre and post treatment time points (T1 and T2) for each patient, the change from T1 to T2 was determined and recorded to the nearest tenth of a millimeter. The change in gingival exposure for the 200

patients was analyzed using the SPSS program and the mean and median values were determined. The mean change in

gingival exposure for the 200 patients was 0.7349 mm while the median change was 0.660 mm suggesting that a homogenous sample of normally distributed patients was obtained (see table 3.1).

48

Table 3.1 Descriptive Statistics for the change in gingival display of the 200 subjects

Mean Change Median Change Standard Deviation Range Minimum Maximum

0.7349 mm 0.660 mm 1.96581 mm 13.87 mm -6.92 mm 6.95 mm

The sample was then divided into three groups: 1.

Group

those that obtained the greatest decrease in gingival Group 2. those that had the

exposure during treatment;

average amount of change during treatment; Group 3. those that obtained the greatest increase in gingival exposure; The groups were developed by taking one standard deviation from the median. Those that obtained a minimum of one standard deviation less than the median change during orthodontic treatment were included in the greatest decrease group or Group 1. The 15 patients on each side of the median made up the average change group or Group 2. Those that obtained a minimum of one standard deviation greater than the median change during treatment were included into the greatest increase group or Group 3.

49

Group 1 contained 21 subjects (8 females and 13 males) and had a mean change of -2.55 mm. Group 2 contained 29 subjects (17 Females and 12 Males) (one was thrown out due to a magnification differential) and had a mean change of 0.65 mm, and group 3 contained 33 subjects (20 females and 13 males) and had a mean change of 3.75 mm (see table 3.2).

Table 3.2:
Group Number of Subjects 21

Description of Sample Groups

Mean Change in Gingival Display (mm) -2.55 Gender Differences 8 Females 13 Males Molar Classifications 8 Class I 9 Class II 4 Class III

1 (Greatest Decrease in Gingival Display) 2 (Average Change in Gingival Display) 3 (Greatest Increase in Gingival Display)

29

0.65

17 Females 12 Males

21 Class I 5 Class II 3 Class III

33

3.75

20 Females 13 Males

19 Class I 11 Class II 3 Class III

50

Data Collection The pre and post treatment cephalometric radiographs of the three groups (83 subjects) were hand traced and 28 soft and hard tissue landmarks were identified(See table 3.3 and figure 3.3). Table 3.3 Landmark abbreviations and descriptions
Landmark Sella Nasion Abbreviation S N Description Midpoint of the cavity of the pituitary fossa of the sphenoid bone Junction of the frontonasal suture at the most posterior point on the curve at the bridge of the nose Tip of the median, sharp bony process of the maxilla at the lower margin of the anterior nasal opening The most posterior point at the sagittal plane on the bony hard palate The most posterior point on the curve of the maxilla between the anterior nasal spine and supradentale The point most posterior to a line from infradentale to pogonion on the anterior surface of the symphyseal outline of the mandible Most anterior point on the contour of the bony chin Most inferior and anterior point on the contour of the bony chin Most inferior point on the symphyseal outline Midpoint of the angle of the mandible Most posterior superior point on the curvature of the average of the right and left outlines of the condylar head Most anterior point on the tip of the nose The point at which the nasal septum mergest, in the midsagittal plane, with the upper lip

Anterior Nasal Spine Posterior Nasal Spine Point A or Subspinale Point B or Supramentale

ANS

PNS A pt

B pt

Pogonion Gnathion Menton Gonion Condylion

Pog Gn Me Go Co

Pronasale Subnasale

Prn Sn

51

Table 3.3 (Continued)

Landmark Labrale Superius Stomion Superius Stomion Inferius Labrale Inferius Soft Tissue Pogonion Maxillary Incisor Apex Maxillary Incisor Incisal Edge Mandibular Incisor Apex Mandibular Incisor Incisal Edge Maxillary First Molar Apex Maxillary First Molar Mesial Cusp Tip Mandibular First Molar Apex Mandibular First Molar Mesial Cusp Tip Posterior Functional Occlusal Plane Anterior Functional Occlusal Plane Abbreviation Ls Ss Si Li Pg U1a Description Most anterior point of lip Most inferior point of lip Most superior point of lip Most anterior point of lip Most anterior point of tissue chin the upper the upper the lower the lower the soft

The root tip of the maxillary central incisor The incisal tip of the maxillary central incisor The root tip of the mandibular central incisor The incisal tip of the mandibular central incisor The root tip of the most anterior root of the maxillary first molar The anterior cusp tip of the maxillary first molar The root tip of the most anterior root of the mandibular first molar The anterior cusp tip of the mandibular first molar The plane that intersects the biting surfaces of the posterior teeth; measured from the distal cusp of the maxillary first molar A point formed by a perpendicular from the tip of the maxillary central incisor to the plane that intersects the biting surfaces of the posterior teeth

U1i L1a L1i U6a U6c L6a L6c PFOP

AFOP

52

Figure 3.3 Cephalometric Landmarks

53

After the cephalometric radiographs were traced, they were digitized, using a Numonic Digitizing Table (model # IPS/BL.E-A30BL.H). Dentofacial Planner 7.0 software was used to translate each landmark into x-y coordinates. The

pre and post treatment cephalometric radiographs of each subject were superimposed on the anterior cranial base (best fit on the planum sphenoid, cribiform plate, greater wings of sphenoid) and registered on sella. Two reference planes were then generated to assist with the cephalometric analysis. A horizontal reference

plane was drawn at the level of the sella-nasion line minus 7 degrees (SN-7). A vertical reference plane (SN-7-

perpendicular) was then drawn through sella, perpendicular to the SN-7 line (see Figure 3.4).! ! ! ! ! ! ! ! ! ! ! 54

! ! ! ! ! ! ! ! ! ! ! ! !
Figure 3.4 Reference Planes

A total of 54 linear measures were made on each cephalometric radiograph at each time point (27 vertical and 27 horizontal) by dropping lines perpendicular to the SN-7 reference plane or SN-7 perpendicular respectively. See Figures 3.5 and 3.6.

55

Figure 3.5 Examples of and vertical measures from the SN-7 the reference plane

Figure 3.6 Examples of Horizontal Measures from the SN-7 Perpendicular reference plane

56

Data Analysis Due to the lack of literature available, all 27 variables were studied to determine which variables are important in gingival display. In order to maintain the power of the analysis, the variables were divided into four groups: soft tissue, maxilla, mandible, and dental.

Paired t tests were used to compare the horizontal and vertical measures within each group at the T1 and T2 time points. An Analysis of Variance was (ANOVA) then used to

compare both the horizontal and vertical measures between each analysis group at each time point (T1 and T2). Because the sample sizes were not equal, the significant measures were compared using Tukeys Post Hoc and a mean sample size of 26 was used. All statistical computations were calculated by means of standard computer software (SPSS for Windows, release 15.0.0, Inc., Chicago, IL). set at P<.05. Statistical significance was

Analysis of Error Due to the potential for human error inherent to the process of landmark identification and tracing cephalometric radiographs, as well as the process of measuring gingival display using a digital caliper on

57

models and photo calibration, 10% of each of the samples was randomly selected for measurement duplication. Twenty subjects were re-measured for reliability of the gingival measures (200 in initial sample), and 9 subjects were remeasured for cephalometric analysis (83 subjects in cephalometric study). All measures were repeated for the cephalometric radiographs, models, and photos. A reliability analysis (intercorrelation coefficient) was performed comparing the initial to the repeated measures. The reliability coefficient was found to range

from 0.995 to 0.999 for the gingival measures and to range from 0.994 to 1.000 for the cephalometric measures.! ! Results The first set of inferential statistics tested for significant differences between each of the groups at the pre-treatment time point. The Analysis of Variance revealed no significant differences between any of the groups for any of the 27 landmarks in either the horizontal or the vertical dimensions at the pretreatment time point (see appendix A Tables A.1A.16). Therefore, all significant

differences found at the post treatment time point can be attributed to change that occurred during treatment.

58

Paired t tests were used to investigate significant differences between the T1 and T2 time points within each of the groups. They revealed significant differences in 25

of the 27 vertical measures for all three groups from the pre treatment to post-treatment time points, as would be expected in a growing sample. The non-significant variables included nasion, which was included in the reference plane, and condylion. The horizontal measures showed more variability. The following horizontal measures were found

to be significant between the T1 and T2 time points for group 1: 3.4). pronasale, subnasale, menton, and gonion (Table

Significant horizontal measures from T1 to T2 for pronasale, A point, B point, Gnathion, All horizontal

group 2 include:

menton, gonion, and L-6 Apex (Table 3.5).

measures were significant between the T1 and T2 time points for group 3 with the exception of nasion, pronasale, subnasale, Posterior functional occlusal plane, Lower 6 tip, and Lower 6 apex (Table 3.6) The following horizontal measures were found to be significantly different at the post-treatment time point between group 1 and group 3: Labrale superius, Stomion

superius, Stomion inferius, and Labrale inferius (tables 3.7-3.9). The non-significant measures at the posttreatment time point appear in Appendix B (tables B.1-

59

B.16). No significant differences were found in the horizontal measures between any of the groups (see Appendix B Tables B.1,B.2, B.5, B.6, B.9, B.10, B.13, B.14), however some tendencies are apparent when the groups are compared at each time point (see Tables: 3.13-3.20). The only

significant vertical measure at the post treatment time point was found between group 2 and group 3 at the condylion measure (tables 3.10-3.12). No other significant

differences were found in the vertical measures at the post treatment time point (see Appendix B Tables B.3, B.4, B.7, B.8, B.11, B.12, B.15, B.16), however as with the horizontal, some tendencies are easily seen when the groups are compared (see Tables 3.13 -3.20).

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Table 3.4 Group 1 Pre-treatment Vs. Post-treatment Variable V Nasion H Nasion V Pronasale H Pronasale V Subnasale H Subnasale V Labrale Superius H Labrale Superius V Stomion Superius H Stomion Superius V Stomion Inferius H Stomion Inferius V Labrale Inferius H Labrale Inferius V Pogion' H Pogion' V ANS H ANS V PNS H PNS V A Point H A Point V B Point H B Point V Pogonion H Pogonion V Gnathion H Gnathion V Menton H Menton V Gonion T1 T2 -8.9381 -8.9571 72.8571 72.9571 37.4381 44.1048 99.1286 50.5952 85.7286 64.6952 90.4857 73.4619 82.919 74.6619 82.2238 82.6143 86.3 106.2333 75.0667 46.5048 70.7095 44.3952 18.2857 49.4667 68.5048 94.6571 61.9048 107.0714 61.3857 111.2476 58.6762 112.3762 54.7905 74.1714 61 102.481 56.0238 87.0762 70.619 90.8762 79.6762 82.5524 80.6 82.3143 89.6571 86.7619 114.019 75.3333 50.6619 69.8714 47.6619 16.9762 54.3952 67.5667 101.0381 61.3286 116.8333 59.881 120.581 56.4238 121.3429 51.8095 78.6714 !T2-T1 Sig -0.019 0.162 0.1 0.241 6.6667 ***0 ** 0.001 3.3524 5.4286 ***0 1.3476 *0.031 5.9238 0.3905 6.2143 -0.3666 5.9381 0.0905 7.0428 0.4619 7.7857 0.2666 4.1571 -0.8381 3.2667 -1.3095 4.9285 -0.9381 6.381 -0.5762 9.7619 -1.5047 9.3334 -2.2524 8.9667 -2.981 4.5 ***0 0.601 ***0 0.731 ***0 0.94 ***0 0.686 ***0 0.823 ***0 0.26 ***0 0.118 ***0 0.139 ***0 0.498 ***0 0.211 ***0 0.092 ***0 *0.046 **0.001

Table 3.4 (Continued) Variable H Gonion V Condylion H Condylion V Post FOP H Post FOP V Ant FOP H Ant FOP V U6 Apex H U6 Apex V L6 Apex H L6 Apex V L6 Tip H L6 Tip V U1 Tip H U1 Tip V U1 Apex H U1 Apex V L1 Tip H L1 Tip V L1 Apex H L1 Apex *p<.05 ** p<.005 *** p<.001 T1 -11.419 23.4714 -19.6095 66.1714 31.9143 76.819 74.5857 48.119 45.1 89.0095 33.2524 68.2619 41.8 76.5048 74.6905 49.2714 62.5905 72.8619 70.9714 92.7238 57.0857 T2 -15.119 22.781 -20.8905 71.7381 32.1667 82.1524 73.319 53.5 44.9905 95.4857 34.0571 74.9143 43.3143 81.8476 73.2381 55.3381 62.4286 79.9762 70.8286 99.6381 56.3619 !T2-T1 -3.7 -0.6904 -1.281 5.5667 0.2524 5.3334 -1.2667 5.381 -0.1095 6.4762 0.8047 6.6524 1.5143 5.3428 -1.4524 6.0667 -0.1619 7.1143 -0.1428 6.9143 -0.7238 Sig **0.002 0.534 0.078 ***0 0.775 ***0 0.253 ***0 0.896 ***0 0.389 ***0 0.089 ***0 0.203 ***0 0.806 ***0 0.878 ***0 0.431

(H = Horizontal Measure; V = Vertical Measure)

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Table 3.5 Group 2 Pre-Treatment Vs. Post-Treatment Variable T1 Nasion -9.1966 Nasion 74.8724 Pronasale 40.1310 Pronasale 101.4414 Subnasale 53.1069 Subnasale 86.7207 Labrale Superius 67.1586 Labrale Superius 88.3931 Stomion Superius 74.8207 Stomion Superius 80.2414 Stomion Inferius 75.8034 Stomion Inferius 79.9517 Labrale Inferius 83.3828 Labrale Inferius 83.8586 Pogion 108.1103 Pogion 73.7966 ANS 47.7379 ANS 72.0586 PNS 45.3379 PNS 16.4276 A Point 51.5655 A Point 68.9414 B Point 94.6897 B Point 61.2414 Pogonion 106.2793 Pogonion 60.8172 Gnathion 106.2793 Gnathion 60.8172 Menton 113.5724 Menton 53.1345 Gonion 74.2448 Gonion -11.6310 Condylion 22.0069 Condylion -20.4931 Post FOP 67.5276000 T2 -9.2000 74.9000 44.7621 103.0793 57.2828 87.0207 71.669 87.7759 78.6172 79.9138 79.4103 79.7724 87.5207 83.8621 113.4828 72.8483 50.9931 71.1207 46.5276 15.3586 55.1517 67.6759 100.4276 59.7207 112.2241 59.3759 112.2241 59.3759 120.2 51.2828 78.1759 -14.4897 23.131 -21.0069 71.5069 !T2-T1 -0.0034 0.0276 4.6311 1.6379 4.1759 0.3000 4.5104 -0.6172 3.7965 -0.3276 3.6069 -0.1793 4.1379 0.0035 5.3725 -0.9483 3.2552 -0.9379 1.1897 -1.0690 3.5862 -1.2655 5.7379 -1.5207 5.9448 -1.4413 5.9448 -1.4413 6.6276 -1.8517 3.9311 -2.8587 1.1241 -0.5138 3.9793 Sig 0.745 0.637 ***0 **0.01 ***0 0.556 ***0 0.326 ***0 0.656 ***0 0.81 ***0 0.996 ***0 0.289 ***0 0.088 *0.024 0.146 ***0 *0.04 ***0 *0.042 ***0 0.076 ***0 *0.044 ***0 *0.026 ***0 ***0 0.202 0.294 ***0

V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V

63

Table 3.5 (Continued) Variable T1 T2 !T2-T1 Sig H Post FOP 31.1517 31.7414 0.5897 0.325 V Ant FOP 77.4966 80.5793 3.0827 ***0 H Ant FOP 72.6034 71.4517 -1.1517 0.063 V U6 Apex 49.3586 53.1345 3.7759 ***0 H U6 Apex 44.1552 43.7379 -0.4173 0.604 V L6 Apex 89.3000 93.7966 4.4966 ***0 H L6 Apex 31.9862 33.3828 1.3966 *0.031 V L6 Tip 69.9448 74.0828 4.1380 ***0 H L6 Tip 41.8207 42.2414 0.4207 0.518 V U1 Tip 77.5345 81.2172 3.6827 ***0 H U1 Tip 72.3552 71.169 -1.1862 0.063 V U1 Apex 51.6310 55.5517 3.9207 ***0 H U1 Apex 63.2724 62.1276 -1.1448 0.065 V L1 Tip 74.2448 79.769 5.5242 ***0 H L1 Tip 69.3517 69.0966 -0.2551 0.683 V L1 Apex 93.6241 98.3862 4.7621 ***0 H L1 Apex 55.6103 54.4276 -1.1827 0.148 * p<.05 ** p<.005 *** p<.001 ( H = Horizontal Measure; V = Vertical Measure)

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Table 3.6 Group 3 Pre-Treatment Vs. Post-Treatment Variable Nasion Nasion Pronasale Pronasale Subnasale Subnasale Labrale Superius Labrale Superius Stomion Superius Stomion Superius Stomion Inferius Stomion Inferius labrale Inferius Labrale Inferius Pogion' Pogion' ANS ANS PNS PNS A Point A Point B Point B Point Pogonion Pogonion Gnathion Gnathion Menton Menton Gonion Gonion Condylion Condylion Post FOP Post FOP Ant FOP Ant FOP U6 Apex T1 -8.9879 73.2333 40.703 98.8152 52.4242 84.3636 66.9152 86.1273 74.0848 78.3091 75.6121 77.9273 83.0394 81.6061 104.997 72.4697 47.0939 71.5424 45.5242 16.7061 51.0606 67.9273 93.7909 58.9879 107.3212 58.6848 112.5182 55.8091 113.6394 50.9333 76.9364 -11.303 21.4606 -19.5061 67.8091 30.4242 77.7667 71.4303 49.7667 65 T2 -8.997 73.2909 46.4364 99.3212 57.6182 83.5636 72.0061 84.8576 78.7636 76.1333 79.7818 75.8939 88.7909 80.1939 112.0848 69.3909 50.8697 69.803 46.9121 14.6212 55.0667 65.9576 99.8061 55.5909 114.1424 55.3364 119.3152 51.9364 120.1485 46.8788 78.4152 -16.403 19.7818 -20.6545 71.0909 29.6455 82.2818 68.5333 53.6485 !T2-T1 -0.0091 0.0576 5.7334 0.506 5.194 -0.8 5.0909 -1.2697 4.6788 -2.1758 4.1697 -2.0334 5.7515 -1.4122 7.0878 -3.0788 3.7758 -1.7394 1.3879 -2.0849 4.0061 -1.9697 6.0152 -3.397 6.8212 -3.3484 6.797 -3.8727 6.5091 -4.0545 1.4788 -5.1 -1.6788 -1.1484 3.2818 -0.7787 4.5151 -2.897 3.8818 Sig 0.374 0.275 ***0 0.32 ***0 0.116 ***0 *0.022 ***0 ***0 ***0 **0.001 ***0 *0.018 ***0 **0.001 ***0 **0.019 ***0 **0.001 ***0 *0.005 ***0 ***0 ***0 ***0 ***0 ***0 ***0 ***0 *0.005 ***0 *0.021 *0.006 ***0 0.171 ***0 ***0 ***0

V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V H V

Variable !T2-T1 Sig H U6 Apex -1.3818 *0.015 V L6 Apex 4.006 ***0 H L6 Apex 0.4546 0.622 V L6 Tip 4.2515 ***0 H L6 Tip 0.2545 0.723 V U1 Tip 4.7333 ***0 H U1 Tip -3.1636 ***0 V U1 Apex 6.1031 ***0 H U1 Apex -1.6879 **0.003 V L1 Tip 6.1728 ***0 H L1 Tip -1.3485 *0.018 V L1 Apex 4.6606 ***0 H L1 Apex -3.3242 ***0 * p<.05 ** p<.005 *** p<.001 ( H= Horizontal measures; V = Vertical Measures)

Table 3.6 (Continued) ! T1 T2 43.2333 41.8515 89.6576 93.6636 30.1545 30.6091 70.0606 74.3121 39.7182 39.9727 77.3576 82.0909 71.5818 68.4182 51.4848 57.5879 61.7727 60.0848 74.003 80.1758 67.203 65.8545 92.8667 97.5273 54.3545 51.0303

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Table 3.7 Descriptive Statistics for Significant Horizontal Landmarks at the Post Treatment Time Point
Landmark H Labrale Superius Group 1.00 2.00< 3.00 Total H Stomion Superius 1.00 2.00< 3.00 Total H Stomion Inferius 1.00 2.00< 3.00 Total H Labrale Inferius 1.00 2.00< 3.00 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 90.8762 87.7759 84.8576 87.4000 82.5524 79.9138 76.1333 79.0783 82.3143 79.7724 75.8939 78.8735 86.7619 83.8621 80.1939 83.1373 Std. Deviation 8.18113 6.50805 7.90668 7.80574 8.29244 7.23714 8.17724 8.22065 8.30170 7.24731 8.24541 8.25628 9.05635 7.71674 8.75171 8.79001 Std. Error 1.78527 1.20852 1.37638 .85679 1.80956 1.34390 1.42348 .90233 1.81158 1.34579 1.43534 .90624 1.97626 1.43296 1.52348 .96483

< denotes Group 2 landmarks that show no significant differences at the post treatment time point; data given for comparison purposes Table 3.8 ANOVA for Significant Horizontal Landmarks at the Post Treatment Time Point
Sum of Squares H Labrale Superius Between Groups Within Groups Total H Stomion Superius Between Groups Within Groups Total H Stomion Inferius Between Groups Within Groups Total H Labrale Inferius Between Groups Within Groups Total
* p<.05 ** p<.005 *** p<.001

df 2 80 82 2 80 82 2 80 82 2 80 82

Mean Square 235.584 56.563 279.950 62.270 282.510 62.808 288.509 71.983

F 4.165

Sig. *0.019

471.168 4525.052 4996.220 559.901 4981.580 5541.481 565.019 5024.602 5589.622 577.018 5758.657 6335.674

4.496

*0.014

4.498

*0.014

4.008

*0.022

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Table 3.9 Tukey Post Hoc Multiple Comparisons Of Significant Horizontal Landmarks at the Post Treatment Time Point
(I) GROUP 1.00 2.00< 3.00 H Stomion Superius 1.00 2.00< 3.00 H Stomion Superius 1.00 2.00< 3.00 H Labrale Superius 1.00 2.00< 3.00 Mean Difference (I-J) 3.10033 6.01861(*) -3.10033 2.91829 -6.01861(*) -2.91829 2.63859 6.41905(*) -2.63859 3.78046 -6.41905(*) -3.78046 2.54187 6.42035(*) -2.54187 3.87847 -6.42035(*) -3.87847 2.89984 6.56797(*) -2.89984 3.66813 -6.56797(*) -3.66813 Std. Error 2.15498 2.09941 2.15498 1.91429 2.09941 1.91429 2.26107 2.20277 2.26107 2.00853 2.20277 2.00853 2.27082 2.21226 2.27082 2.01719 2.21226 2.01719 2.43104 2.36835 2.43104 2.15951 2.36835 2.15951

Dependent Variable H Labrale Superius

(J) GROUP 2.00 3.00 1.00 3.00 1.00 2.00 2.00 3.00 1.00 3.00 1.00 2.00 2.00 3.00 1.00 3.00 1.00 2.00 2.00 3.00 1.00 3.00 1.00 2.00

Sig. 0.326 *0.014 0.326 0.285 *0.014 0.285 0.476 *0.013 0.476 0.150 *0.013 0.150 0.505 *0.013 0.505 0.139 *0.013 0.139 0.461 *0.019 0.461 0.212 *0.019 0.212

* p<.05 ** p<.005 *** p<.001 < denotes group 2 landmarks that show no significant differences at the post treatment time point; data given for comparison purposes

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Table 3.10 Descriptive Statistics for the Significant Vertical Landmark at the Post Treatment Time Point Std. Std. Group N Mean Deviation Error 1.00< 21 22.7810 5.82019 1.27007 2.00 29 23.1310 5.20763 .96703 3.00 33 19.7818 4.78621 .83317 Total 83 21.7108 5.38202 .59075 < denotes group 1 landmarks that show no significant differences at the post treatment time point; data given for comparison purposes Table 3.11 ANOVA for the Significant Vertical Measure at the Post Treatment Time Point Sum of Squares V Condylion Between Groups Within Groups Total
* p<.05 ** p<.005*** *** p<.001

Landmark V Condylion

df 2 80 82

Mean Square 102.668 27.124

F 3.785

Sig. *.027

205.337 2169.884 2375.220

Table 3.12 Tukeys Post Hoc Multiple Comparisons of the Significant Vertical Landmark at the Post Treatment Time Point Dependent Variable V Condylion (I) GROUP 1.00< 2.00 3.00
* p<.05 ** p<.005 *** p<.001

(J) GROUP 2.00 3.00 1.00< 3.00 1.00< 2.00

Mean Difference (I-J) -.35008 2.99913 .35008 3.34922(*) -2.99913 -3.34922(*)

Std. Error 1.49228 1.45380 1.49228 1.32560 1.45380 1.32560

Sig. 0.970 0.104 0.970 *0.036 0.104 *0.036

< denotes group 1 landmarks that show no significant differences at the post treatment time point; data given for comparison purposes

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Table 3.13 Comparison of Mandibular Horizontal Measures at the T1 and T2 Time Points Landmark H BPt Group 1 2 3 Total H Pog 1 2 3 Total H Gn 1 2 3 Total H Me 1 2 3 Total H Go 1 2 3 Total H Co 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 61.9048 61.2414 58.9879 60.5133 61.3857 60.8172 58.6848 60.1133 58.6762 58.1448 55.8091 57.3506 54.7905 53.1345 50.9333 52.6783 -11.419 -11.631 -11.303 -11.447 -19.6095 -20.4931 -19.5061 -19.8771 T2 60.935 59.7207 55.5909 58.3549 59.881 59.3759 55.3364 57.8976 56.4238 56.4414 51.9364 54.6458 51.8095 51.2828 46.8788 49.6651 -15.119 -14.4897 -16.403 -15.4096 -20.8905 -21.0069 -20.6545 -20.8373 change -0.9698 -1.5207 -3.397 -2.1584 -1.5047 -1.4413 -3.3484 -2.2157 -2.2524 -1.7034 -3.8727 -2.7048 -2.981 -1.8517 -4.0545 -3.0132 -3.7 -2.8587 -5.1 -3.9626 -1.281 -0.5138 -1.1484 -0.9602

70

Table 3.14 Comparison of Mandibular Vertical Measures at T1 and T2 Landmark V BPt Group 1 2 3 Total V Pog 1 2 3 Total V Gn 1 2 3 Total V Me 1 2 3 Total V Go 1 2 3 Total V Co 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 94.6571 94.6897 93.7909 94.3241 107.0714 106.2793 107.3212 106.894 111.2476 111.7655 112.5182 111.9337 112.3762 113.5724 113.6394 113.2964 74.1714 74.2448 76.9364 75.2964 23.4714 22.0069 21.4606 22.1602 T2 Mean 101.0381 100.4276 99.8061 100.3349 116.8333 112.2241 114.1424 114.153 120.581 118.469 119.3152 119.3398 121.3429 120.2 120.1485 120.4687 78.6714 78.1759 78.4152 78.3964 22.781 23.131 19.7818 21.7108 Change 6.381 5.7379 6.0152 6.0108 9.7619 5.9448 6.8212 7.259 9.3334 6.7035 6.797 7.4061 8.9667 6.6276 6.5091 7.1723 4.5 3.9311 1.4788 3.1 -0.6904 1.1241 -1.6788 -0.4494

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Table 3.15 Comparison of the Horizontal Maxillary Landmarks at T1 and T2 Landmark H ANS Group 1 2 3 Total H PNS 1 2 3 Total H APt 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 70.7095 72.0586 71.5424 71.512 18.2857 16.4276 16.7061 17.0084 68.5048 68.9414 67.9273 68.4277 T2 Mean 69.8714 71.1207 69.803 70.2807 16.9762 15.3586 14.6212 15.4747 67.5667 67.6759 65.9576 66.9651 Change -0.8381 -0.9379 -1.7394 -1.2313 -1.3095 -1.069 -2.0849 -1.5337 -0.9381 -1.2655 -1.9697 -1.4626

Table 3.16 Comparison of Vertical Maxillary Landmarks at T1 and T2 Landmark V ANS Group 1 2 3 Total V PNS 1 2 3 Total V APt 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 46.5048 47.7379 47.0939 47.1699 44.3952 45.3379 45.5242 45.1735 49.4667 51.5655 51.0606 50.8337 T2 Mean 50.6619 50.9931 50.8697 50.8602 47.6619 46.5276 46.9121 46.9675 54.3952 55.1517 55.0667 54.9265 Change 4.1571 3.2552 3.7758 3.6903 3.2667 1.1897 1.3879 1.794 4.9285 3.5862 4.0061 4.0928

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Table 3.17 Comparison of Horizontal Soft Tissue Landmarks at T1 and T2 Landmark H PRN Group 1 2 3 Total H SBN 1 2 3 Total H LS 1 2 3 Total H SS 1 2 3 Total H SI 1 2 3 Total H LI 1 2 3 Total H POG 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 99.1286 101.4414 98.8152 99.812 85.7286 86.7207 84.3636 85.5325 90.4857 88.3931 86.1273 88.0217 82.919 80.2414 78.3091 80.1506 82.2238 79.9517 77.9273 79.7217 86.3 83.8586 81.6061 83.5807 75.0667 73.7966 72.4697 73.5904 T2 Mean 102.481 103.0793 99.3212 101.4337 87.0762 87.0207 83.5636 85.6602 90.8762 87.7759 84.8576 87.4 82.5524 79.9138 76.1333 79.0783 82.3143 79.7724 75.8939 78.8735 86.7619 83.8621 80.1939 83.1373 75.3333 72.8483 69.3909 72.1024 Change 3.3524 1.6379 0.506 1.6217 1.3476 0.3 -0.8 0.1277 0.3905 -0.6172 -1.2697 -0.6217 -0.3666 -0.3276 -2.1758 -1.0723 0.0905 -0.1793 -2.0334 -0.8482 0.4619 0.0035 -1.4122 -0.4434 0.2666 -0.9483 -3.0788 -1.488

73

Table 3.18 Comparison of Vertical Soft Tissue Landmarks at T1 and T2 Landmark V PRN Group 1 2 3 Total V SBN 1 2 3 Total V LS 1 2 3 Total V SS 1 2 3 Total V SI 1 2 3 Total V LI 1 2 3 Total V POG 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 37.4381 40.131 40.703 39.6771 50.5952 53.1069 52.4242 52.2 64.6952 67.1586 66.9152 66.4386 73.4619 74.8207 74.0848 74.1843 74.6619 75.8034 75.6121 75.4386 82.6143 83.3828 83.0394 83.0518 106.2333 108.1103 104.997 106.3976 T2 Mean 44.1048 44.7621 46.4364 45.2614 56.0238 57.2828 57.6182 57.0976 70.619 71.669 72.0061 71.5373 79.6762 78.6172 78.7636 78.9434 80.6 79.4103 79.7818 79.859 89.6571 87.5207 88.7909 88.5663 114.019 113.4828 112.0848 113.0627 Change 6.6667 4.6311 5.7334 5.5843 5.4286 4.1759 5.194 4.8976 5.9238 4.5104 5.0909 5.0987 6.2143 3.7965 4.6788 4.7591 5.9381 3.6069 4.1697 4.4204 7.0428 4.1379 5.7515 5.5145 7.7857 5.3725 7.0878 6.6651

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Table 3.19 Comparison of Horizontal Dental Landmarks at T1 and T2 Landmark H PFOP Group 1 2 3 Total H AFOP 1 2 3 Total H U6A 1 2 3 Total H L6A 1 2 3 Total H L6C 1 2 3 Total H U1C 1 2 3 Total H U1A 1 2 3 Total H L1I 1 2 3 Total H L1A 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 31.9143 31.1517 30.4242 31.0554 74.5857 72.6034 71.4303 72.6386 45.1 44.1552 43.2333 44.0277 33.2524 31.9862 30.1545 31.5783 41.8 41.8207 39.7182 40.9795 74.6905 72.3552 71.5818 72.6386 62.5905 63.2724 61.7727 62.5036 70.9714 69.3517 67.203 68.9072 57.0857 55.6103 54.3545 55.4843 T2 Mean 32.1667 31.7414 29.6455 31.0157 73.319 71.4517 68.5333 70.7639 44.9905 43.7379 41.8515 43.3048 34.0571 33.3828 30.6091 32.4506 43.3143 42.2414 39.9727 41.6108 73.2381 71.169 68.4182 70.5988 62.4286 62.1276 60.0848 61.3916 70.8286 69.0966 65.8545 68.2458 56.3619 54.4276 51.0303 53.5663 Change 0.2524 0.5897 -0.7787 -0.0397 -1.2667 -1.1517 -2.897 -1.8747 -0.1095 -0.4173 -1.3818 -0.7229 0.8047 1.3966 0.4546 0.8723 1.5143 0.4207 0.2545 0.6313 -1.4524 -1.1862 -3.1636 -2.0398 -0.1619 -1.1448 -1.6879 -1.112 -0.1428 -0.2551 -1.3485 -0.6614 -0.7238 -1.1827 -3.3242 -1.918

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Table 3.20 Comparison of Vertical Dental Landmarks at T1 and T2 Landmark V PFOP Group 1 2 3 Total V AFOP 1 2 3 Total V U6A 1 2 3 Total V L6A 1 2 3 Total V U6C 1 2 3 Total V L6C 1 2 3 Total V U1I 1 2 3 Total V U1A 1 2 3 Total V L1I 1 2 3 Total V L1A 1 2 3 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 T1 Mean 66.1714 67.5276 67.8091 67.2964 76.819 77.4966 77.7667 77.4325 48.119 49.3586 49.7667 49.2072 89.0095 89.3 89.6576 89.3687 68.081 69.5828 69.8697 69.3169 68.2619 69.9448 70.0606 69.5651 76.5048 77.5345 77.3576 77.2036 49.2714 51.631 51.4848 50.9759 72.8619 74.2448 74.003 73.7988 92.7238 93.6241 92.8667 93.0952 T2 Mean 71.7381 71.5069 71.0909 71.4 82.1524 80.5793 82.2818 81.6542 53.5 53.1345 53.6485 53.4313 95.4857 93.7966 93.6636 94.1711 74.3286 73.669 73.5909 73.8048 74.9143 74.0828 74.3121 74.3843 81.8476 81.2172 82.0909 81.7241 55.3381 55.5517 57.5879 56.3072 79.9762 79.769 80.1758 79.9831 99.6381 98.3862 97.5273 98.3614 Change 5.5667 3.9793 3.2818 4.1036 5.3334 3.0827 4.5151 4.2217 5.381 3.7759 3.8818 4.2241 6.4762 4.4966 4.006 4.8024 6.2476 4.0862 3.7212 4.4879 6.6524 4.138 4.2515 4.8192 5.3428 3.6827 4.7333 4.5205 6.0667 3.9207 6.1031 5.3313 7.1143 5.5242 6.1728 6.1843 6.9143 4.7621 4.6606 5.2662

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Discussion

Design The design of this retrospective study was aimed to produce a truly randomized sample without selection bias. To this end, all of the initial 200 patients were included in the study despite the resulting occlusion or amount of gingival display produced or eliminated during orthodontic treatment. Because the change in gingival display obtained

during orthodontic treatment was the sole factor used to create the groups, without respect to the initial gingival display presented, the subjects in the greatest increase in gingival display group could or could not have obtained a gummy smile during orthodontic treatment, just as those in the greatest decrease in gingival display group could or could not have obtained a certain result. This study investigated the change in gingival display or relation of the upper lip to the maxillary teeth during treatment and attempted to determine what, if any, cephalometric landmark changes occurred to produce this change in lip drape without introducing the selection bias that would be produced by selecting only those that had excessive gingival display after orthodontic treatment as has been done in the past.

77

Findings This study evaluated the pre-treatment and posttreatment cephalometric radiographs of three groups of subjects that experienced different changes in gingival display during orthodontic treatment. The purpose of this

study was to determine if there are any pre-treatment cephalometric characteristics that are associated with the tendency to develop a gingival smile during orthodontic treatment and what cephalometric changes occur to produce changes in gingival display. The ANOVA found no significant differences between the three groups at the pre-treatment time point for any of the variables. However, group 1 appears to have the tendency

to have more protrusive lips, a more forward dentition, a more forward positioned mandible, and shorter ramus than the average group. On the contrary, group 3 had the

tendency to have the lips, dentition, and mandible positioned posteriorly and a longer ramus relative to the average group. The paired T tests revealed many significant vertical changes between the T1 and T2 time points, as would be expected in subjects beginning treatment between the age of 10 and 14; this effect is due to growth. All vertical

measures were significant within each group between the T1

78

and T2 time points except for Nasion and Condylion.

This

indicates that all groups changed significantly vertically during the treatment period. However, further

investigation suggests that group 1 had the tendency to obtain the greatest vertical changes, followed by group 3, and finally group 2. In fact, group 1 obtained the

greatest vertical changes in all variables except condylion and the maxillary incisor apex. The horizontal measures demonstrated more variability. While all groups had some significant horizontal differences within the group from the T1 to T2 time period, Group 3 (the greatest increase group) had more variables change significantly in the horizontal direction from the T1 to T2 time period that the other groups. The significant horizontal changes in Group 1, the greatest decrease group, occurred at pronasale, subnasale, menton, and gonion suggesting that only the nasal soft tissue and the lower border of the mandible changed significantly in the horizontal direction. The data

reveals that the soft tissue moved forward as would be expected, and the lower border of the mandible moved backward. The other tendencies, although not significant,

were for the soft tissue and mandibular first molar to move forward, the teeth to move relatively little horizontally,

79

although slightly back, and the maxilla and other mandibular points to move backward. In group 2, only pronasale, A point, B point, Gnathion, menton, gonion, and L-6 Apex changed significantly in the horizontal direction from T1 to T2. The data suggests that the maxilla and mandible moved significantly in the backward direction, while pronasale and the mandibular first molar apex moved forward. The

other tendencies, although not significant, include the soft tissue remaining relatively the same, the teeth moving forward, and the other maxillary and mandibular points moving backward. In Group 3, all horizontal measures were significant with the exception of Nasion, Pronasale, subnasale, Posterior Functional Occlusal Plane, and the mandibular first molar tip and apex. Further examination reveals that all significant horizontal changes in Group 3 occurred in the backward direction. In fact, all horizontal changes in

the soft tissue, maxilla, mandible, and teeth were in the backward direction with the exception of nasion, pronasale, and the mandibular first molar. The mean horizontal and vertical measures of each of the landmarks were plotted on an X-Y axis and used to produce a graphical representation of the changes from T1

80

to T2 for each of the groups.(See Figures 3.6, 3.7, and 3.8)

Figure 3.6 Group 1

81

Figure 3.7 Group 2

82

Figure 3.8 Group 3

83

From these figures it is apparent that all three groups experienced significant downward change during treatment, probably due to both growth and the extrusive effects of treatment. However, group 1 experienced the most vertical change, followed by group 3, and finally by group 2. While the maxilla and mandible move slightly in the

backward direction in groups 1 and 2, the soft tissue, teeth,and overall growth vector tend to be in a downward and forward direction, although more downward in the group 1. In group 3, all variables have a downward and backward

vector with the exception of the tip of the nose and the mandibular molar. Although the ANOVA did not detect any significant differences in the horizontal position of the maxilla, mandible, or teeth between the groups at the post treatment time point, it appears that the cumulative effects of the individual components affected the soft tissue of the lips (labrale superius, stomion superius, stomion inferius, and labrale inferius) to a significant degree between the two extreme groups (groups 1 and 3). The soft tissue lips were

significantly further back in the greatest increase group, group 3, than the greatest decrease group, group 1, at the post treatment time point. This is not surprising as the

average lips moved backward during treatment in group 3,

84

while the lips stayed relatively the same, or moved slightly forward in group 1. Because the ANOVA found no

significant differences in these or any other variable at the pretreatment time point, these differences can be attributed to a change that occurred during treatment. The only significant vertical measure was Condylion between groups 2 and 3. It appears that the condyle moved

significantly more in an upward direction in the greatest increase group (group 3) than the average group (group 2), which stayed relatively the same. Group 1 had a tendency to have a vertical vector of growth as well, although not to a significant degree. The other mandibular measures showed

similar amounts of downward change, with group 1 having a slight tendency to obtain more downward change at the pogonion and gnathion measures, followed by group 3, and finally group 2. This trend for group 1 to obtain the greatest vertical change was apparent in the maxillary and dental vertical measures as well. However, the trend for

group 3 to obtain greater vertical changes than group 2 was not as clear in these measures. The soft tissues demonstrated some interesting post treatment tendencies. There appears to be a tendency for

pronasale, subnasale, and labrale superius, stomion superius, stomion inferius, and labrale inferius to start

85

treatment higher vertically in the greatest decrease group than the greatest increase group. However, at the post

treatment time point, while pronasale, subnasale, and labrale superius, remain more superior vertically in the greatest decrease group, stomion superius, stomion inferius, and labrale inferius are positioned inferior to the same landmarks in group 3. It appears that although

the nose and superior most point on the upper lip retain their pattern, the point where the upper lip meets the lower lip moves more inferiorly during treatment in group 1 than group 3. This suggests that a lip response to treatment could be an important factor in gingival display. The data suggests that the lips responded to the vertical component of growth (or change) in group 1, but did not respond in a similar fashion in group 3. Perhaps this lack of downward

movement of the point where the lips meet in group 3 could be a function of the significant movement of the lips horizontally backward during treatment. In summary, the soft tissue lips and skeletal vertical condylion were the only significant differences found between the groups. However, further examination and

plotting of the mean X-Y location of each of the points and the pre and post treatment time points reveal a generalized

86

tendency for the greatest decrease group, or group 1 to have a large vertical component, as well as a forward component. The average group, or group 2, has the tendency

to change in the typical downward and forward pattern, and the greatest increase group, or group 3, has the tendency to change in a slightly increased downward and backward direction. Further examination of the lips suggests that the lips of subjects in group 1 responded vertically to the inferior vector of change during treatment, while the lips of subjects in group 3 did respond in a similar fashion. This suggests that the significant horizontal (backward) movement of the lips during treatment affected the downward response. Aside from dental and skeletal components, other considerations in gingival display suggested by the literature are sex, molar classification, and lip length. In this study, 61% of the greatest increase group, group 3, were female (39% male). Accordingly, 62% of the greatest

decrease group, group 1, were male (38% female. Although weak, this tendency is in agreement with the literature, which suggests that the tendency to have a gingival smile is predominantly a female characteristic, while a low smile line is predominantly a male characteristic.4,3,5,6 The middle group was

87

59% female and 41% male, which closely resembles the original sample which was 57% female and 43% male (see Table 3.21.)
Table 3.21 Group Gender Percentages Group Number of Subjects 21 29 33 Mean Change in Gingival Display -2.55 0.65 3.75 Gender Differences 8 Females 13 Males 17 Females 12 Males 20 Females 13 Males Percentages

1 2 3

38% Female 62% Male 59% Female 41% Male 61% Female 39% Male

When lip length of the sample is investigated, it appears that although insignificant, group 3, who obtained the greatest increase in gingival display, tends to have a slightly shorter lip length at T1, while group 1, the greatest decrease group, tends to have the longest lip length at T1 (see Table 3.22). For this purpose, lip

length was defined as the vertical length from subnasale to stomion superius as defined by Peck et al.3 This finding is consistent with the findings of Peck et al. who found no significant difference in upper lip length between his gingival smile group and reference group3 and Schendel et al. who reported that surgical vertical maxillary excess patients have normal lip lengths.7 The mean lip lengths found were also in accordance with the reported normal

88

lip lengths at approximately 22 mm.

However, the tendency

found is contrary to the findings of Singer who found that his group of gingival smile subjects had significantly longer lip lengths than his non-gingival display sample.8
Table 3.22 Mean Lip Length at T1 Group 1 2 3 N 21 29 33 VSBN1 50.5952 53.1069 52.4242 VSTMSU1 73.4619 74.8207 74.0848 Lip Length 22.8667 21.7138 21.6606

When the lip length at the T2 time point is examined, this same trend continues (see table 3.23). However, when

the change in lip length from T1 to T2 is examined, it appears that the greatest decrease in gingival display group, group 1, had an increase in lip length between the T1 and T2 time points, while the average group and the greatest increase groups experienced a decrease in lip length during treatment (see table 3.24)
Table 3.23 Mean Lip Length at T2 Group 1 2 3 N 21 29 33 VSBN2 56.0238 57.2828 57.6182 VSTMSU2 79.6762 78.6172 78.7636 Lip Length 23.6524 21.3344 21.1454

Table 3.24 Change in Mean Lip Length from T1 to T2 Group 1 2 3 N 21 29 33 T1 Lip Length 22.8667 21.7138 21.6606 T2 Lip Length 23.6524 21.3344 21.1454 Change 0.7857 -0.3794 -0.5152

89

When the molar classification of the three groups is considered it appears that groups 2 and 3 have a larger number of subjects with a class I molar classification, groups 1 and 3 have a large number of class II subjects, and all groups have approximately the same number of class III subjects (see Table 3.25).

Table 3.25 Group Molar Classification Molar Classification Class I Crowding Class II Division 1 Division 2 Total Class III Group 1 8 2 2 5 9 4 Group 2 21 4 1 0 5 3 Group 3 19 4 7 0 11 3

Upon further examination, 75% of group 2, the average group, was Class I molar. While groups 1 and 3 have large percentages of Class Is as well, 38% and 58% respectively, Class IIs also demonstrate a strong presence in these groups (43% and 33%). The Class III subjects, although small in number, make up almost 20% of the greatest decrease group, group 1 (see Table 3.26).

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Table 3.26 Molar Classification Percentages Group 1 (N=21) 2 (N=29) 3 (N=33) Class I Class II 43 % (9) 17 % (5) 33 % (11) Class III 19 % (4) 10 % (3) 9 % (3)

38 % (8) 73 % (21) 58 % (19)

When the Class II subjects are examined, of the 25 Class II subjects in the sample, 36% of them are in group 1, the greatest decrease group, and it appears that the majority of the Class II subjects in group 1 are Division 2 (56%). In fact, the only Class II Division 2 subjects in the sample, are in the greatest decrease group. 20% of the class II subjects were in group 2, the average group. The majority of the Class II subjects in group 2 are Class II crowding subjects (80%). 44% of the class II subjects are

in group 3, and the majority of the Class II subjects in group 3, the greatest increase group, are division 1 (64%)(see Tables 3.27 and 3.28).
Table 3.27 Group Percentages of Class IIs Group 1 2 3 Number of Class IIs 9 5 11 Percentage of Class II Subjects in Group 36% 20% 44%

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Table 3.28 Class II Division Percentages Group 1 2 3 Crowding 2 (22%) Division 1 2 (22%) 1 (20%) 7 (64%) Division 2 5 (56%) 0 0 Total 9 5 11

4 (80%) 4 (36%)

Although no clear conclusions can be drawn from the Class I group, it appears that the Class II division groups tend to experience either a great decrease or a great increase in gingival display during treatment. This study

suggests that Class II division 1 subjects tend to experience a great increase in gingival display, and Class II division 2 subjects experience a great decrease. It

also suggests a slight tendency for Class III subjects to experience a great decrease. In conclusion, while no significant differences were found at the pre-treatment time point to suggest one specific pretreatment characteristic to identify patients with the predisposition to experience an increase or decrease in gingival display during treatment, the tendency was for the greatest decrease group, group 1, to be male, to be Class I, Class II division 2, or Class III, to have slightly protrusive lips, teeth and mandibles, and short

92

rami in comparison to the average group.

The greatest

increase group, group 3, tended to be female, to be Class I or Class II crowding or division 1, and to have posteriorly positioned maxillary, mandibular, and dental landmarks in comparison to the average group with the exception of gonion, which suggests a high mandibular plane angle. also had longer rami than the average group. Therefore, careful study of cephalometric measures in the pretreatment radiograph for a pattern of anteriorly or posteriorly positioned landmarks while considering the sex of the patient and molar classification, might help a clinician to recognize those that will have the tendency to lose or gain gingival display during treatment. While no specific maxillary, mandibular, or dental movements can be identified to determine which movements during treatment caused these patterns of change, it appears that a strong downward vector of growth (or change) during treatment can cause a decrease in gingival display, while a downward and backward vector can produce a great increase. Therefore, mechanics aimed toward preventing a They

backward horizontal vector of change and instead promoting a forward horizontal vector, could help to prevent an excessive increase in gingival display during treatment,

93

while controlling the vertical in forward growers appears to be important in preventing an excessive decrease.

Conclusions 1. No significant differences were found at the pretreatment time point, therefore no specific dental, skeletal, or soft tissue characteristic can be identified to predict an increase or decrease in gingival display during orthodontic treatment. 2. The only vertical significant difference was found at the post-treatment time point between the average change group and the greatest increase group at condylion; this significance is possibly due to the large envelope of error at the condylion landmark. 3. The significant horizontal differences were found between the greatest increase and greatest decrease groups at labrale superius, stomion superius, stomion inferius, and labrale inferius (the lips). The lips

moved significantly backward in the greatest increase group while they stayed relatively the same in the greatest decrease group. 4. Although not significant, the greatest decrease group had a tendency to be male, have slightly protrusive lips, forward positioned teeth and mandibles, and

94

shorter rami in comparison to the average group at the pre-treatment time point. They experienced a The

large vertical vector in change from T1 to T2.

greatest increase group had a tendency to be female, have posteriorly positioned maxillary, mandibular, and dental landmarks, and longer rami in comparison to the average group at the pre-treatment time point. They tend to have a downward and backward vector in change from T1 to T2. 5. The change in gingival display during orthodontic treatment is a very complex phenomenon that is a culmination of the affects of changes that occur in the dental, skeletal, and soft tissue components. Further research is warranted.

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Appendix A: Nonsignificant Pre-treatment Data

Table A.1 Pre-Treatment Horizontal Mandibular Measures Descriptive Statistics
Std. Deviation 7.77628 7.13930 8.31147 7.79302 8.89260 7.62239 9.21158 8.58203 9.54950 8.12604 9.53272 9.04886 10.33073 8.46502 9.67954 9.46061 5.28182 5.56431 6.03057 5.62044 3.84459 3.30270 3.44329

Landmark APBPT1

Group 1.00 2.00 3.00 Total

N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33

Mean 61.9048 61.2414 58.9879 60.5133 61.3857 60.8172 58.6848 60.1133 58.6762 58.1448 55.8091 57.3506 54.7905 53.1345 50.9333 52.6783 -11.4190 -11.6310 -11.3030 -11.4470 19.6095 20.4931 19.5061

Std. Error 1.69692 1.32574 1.44684 .85540 1.94052 1.41544 1.60353 .94200 2.08387 1.50897 1.65943 .99324 2.25435 1.57192 1.68499 1.03844 1.15259 1.03327 1.04979 .61692 .83896 .61330 .59940

APPOG1

1.00 2.00 3.00 Total

APGN1

1.00 2.00 3.00 Total

APME1

1.00 2.00 3.00 Total

APGO1

1.00 2.00 3.00 Total

APCO1

1.00 2.00 3.00

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Table A.2 ANOVA for Pre-Treatment Horizontal Mandibular Measures

Landmark APBPT1

Between Groups Within Groups Total

Sum of Squares 132.820 4847.135 4979.955 115.706 5923.690 6039.395 133.610 6580.697 6714.307 200.204 7139.057 7339.261 1.683 2588.644 2590.327 17.051 980.436 997.487

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

Mean Square 66.410 60.589 57.853 74.046 66.805 82.259 100.102 89.238 .841 32.358 8.526 12.255

F 1.096

Sig. .339

APPOG1

Between Groups Within Groups Total

.781

.461

APGN1

Between Groups Within Groups Total

.812

.448

APME1

Between Groups Within Groups Total

1.122

.331

APGO1

Between Groups Within Groups Total

.026

.974

APCO1

Between Groups Within Groups Total

.696

.502

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Table A.3 Pre-Treatment Vertical Mandibular Measures: Statistics

Group 1.00 2.00 3.00 Total VPOG1 1.00 2.00 3.00 Total VGN1 1.00 2.00 3.00 Total VME1 1.00 2.00 3.00 Total VGO1 1.00 2.00 3.00 Total VCO1 1.00 2.00 3.00 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 94.6571 94.6897 93.7909 94.3241 107.0714 106.2793 107.3212 106.8940 111.2476 111.7655 112.5182 111.9337 112.3762 113.5724 113.6394 113.2964 74.1714 74.2448 76.9364 75.2964 23.4714 22.0069 21.4606 22.1602 Std. Deviation 9.30589 8.75905 5.73663 7.76865 10.14934 9.05891 6.77227 8.44151 9.99828 8.81473 6.81425 8.32478 9.73539 8.50466 6.79333 8.13111 6.67661 6.33283 7.24939 6.84639 4.14562 3.86993 4.30319 4.14458

Descriptive

VBPT1

Std. Error 2.03071 1.62651 .99862 .85272 2.21477 1.68220 1.17890 .92658 2.18180 1.63685 1.18621 .91376 2.12444 1.57928 1.18257 .89251 1.45696 1.17598 1.26196 .75149 .90465 .71863 .74909 .45493

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Table A.4 ANOVA for Pre-Treatment Vertical Mandibular Measures

Sum of Squares 15.586 4933.266 4948.852 17.641 5825.606 5843.247 21.979 5660.787 5682.766 23.874 5397.555 5421.429 147.398 3696.191 3843.589 52.939 1355.620 1408.559

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VBPT1

Between Groups Within Groups Total

Mean Square 7.793 61.666 8.821 72.820 10.989 70.760 11.937 67.469 73.699 46.202 26.469 16.945

F .126

Sig. .881

VPOG1

Between Groups Within Groups Total

.121

.886

VGN1

Between Groups Within Groups Total

.155

.856

VME1

Between Groups Within Groups Total

.177

.838

VGO1

Between Groups Within Groups Total

1.595

.209

VCO1

Between Groups Within Groups Total

1.562

.216

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Table A.5 Pretreatment Horizontal Maxillary Measures: Statistics

Landmark APANS1 Group 1.00 2.00 3.00 Total APPNS1 1.00 2.00 3.00 Total APAPT1 1.00 2.00 3.00 Total N 21 29 33 83 21 29 33 83 21 29 33 83 Mean 70.7095 72.0586 71.5424 71.5120 18.2857 16.4276 16.7061 17.0084 68.5048 68.9414 67.9273 68.4277 Std. Deviation 4.26555 5.39931 5.85657 5.29607 3.76713 4.57469 4.52299 4.37775 4.35367 5.52323 6.11455 5.46129

Descriptive

Std. Error .93082 1.00263 1.01950 .58132 .82206 .84950 .78735 .48052 .95005 1.02564 1.06441 .59945

Table A.6 ANOVA for Pretreatment Horizontal Maxillary Measures

Sum of Squares 22.219 2277.749 2299.968 47.062 1524.442 1571.504 16.041 2429.665 2445.706

Landmark APANS1

df 2 80 82 2 80 82 2 80 82

Between Groups Within Groups Total

Mean Square 11.109 28.472 23.531 19.056 8.020 30.371

F .390

Sig. .678

APPNS1

Between Groups Within Groups Total

1.235

.296

APAPT1

Between Groups Within Groups Total

.264

.769

100

Table A.7 Pretreatment Vertical Maxillary Measures: Statistics

Landmark VANS1 Group 1.00 2.00 3.00 Total VPNS1 1.00 2.00 3.00 Total VAPT1 1.00 2.00 3.00 Total N 21 29 33 83 21 29 33 83 21 29 33 83 Mean 46.5048 47.7379 47.0939 47.1699 44.3952 45.3379 45.5242 45.1735 49.4667 51.5655 51.0606 50.8337 Std. Deviation 4.36411 3.92368 4.10449 4.08733 4.04419 3.71785 3.06982 3.54975 4.08978 3.94609 3.88514 3.99699

Descriptive

Std. Error .95233 .72861 .71450 .44864 .88251 .69039 .53439 .38964 .89246 .73277 .67632 .43873

Table A.8 ANOVA for Pretreatment Vertical Maxillary Measures Sum of Squares APANS1 Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total 22.219 2277.749 2299.968 47.062 1524.442 1571.504 16.041 2429.665 2445.706 Mean Square 2 80 82 2 80 82 2 80 82 8.020 30.371 .264 .769 23.531 19.056 1.235 .296 11.109 28.472

df

F .390

Sig. .678

APPNS1

APAPT1

101

Table A.9 Pretreatment Horizontal Dental Measures: Statistics

N APU6DCUSP1 1.00 2.00 3.00 Total APANTFOP1 1.00 2.00 3.00 Total APU6APEX1 1.00 2.00 3.00 Total APL6APEX1 1.00 2.00 3.00 Total APL6TIP1 1.00 2.00 3.00 Total APU1TIP1 1.00 2.00 3.00 Total APU1APEX1 1.00 2.00 3.00 Total APL1TIP1 1.00 2.00 3.00 Total APL1APEX1 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 31.9143 31.1517 30.4242 31.0554 74.5857 72.6034 71.4303 72.6386 45.1000 44.1552 43.2333 44.0277 33.2524 31.9862 30.1545 31.5783 41.8000 41.8207 39.7182 40.9795 74.6905 72.3552 71.5818 72.6386 62.5905 63.2724 61.7727 62.5036 70.9714 69.3517 67.2030 68.9072 57.0857 55.6103 54.3545 55.4843 Std. Deviation 5.63784 5.92119 5.60820 5.68778 8.65981 6.57634 7.24027 7.42123 5.03329 5.46956 5.24289 5.26075 7.25869 7.16986 7.05120 7.16935 6.78454 5.76878 6.47150 6.32430 8.70028 6.54209 7.40107 7.48388 4.69978 5.28711 5.30190 5.13110 8.42117 6.41737 7.68820 7.53363 8.77863 7.00349 7.72812 7.74774

Descriptive

Std. Error 1.23028 1.09954 .97626 .62431 1.88973 1.22120 1.26037 .81459 1.09835 1.01567 .91267 .57744 1.58398 1.33141 1.22746 .78694 1.48051 1.07124 1.12654 .69418 1.89856 1.21484 1.28836 .82146 1.02558 .98179 .92294 .56321 1.83765 1.19167 1.33834 .82692 1.91565 1.30051 1.34529 .85042

102

Table A.10 ANOVA for Pre-Treatment Horizontal Dental Measures

Sum of Squares 28.906 2623.859 2652.765 127.832 4388.285 4516.117 45.441 2223.945 2269.386 130.572 4084.189 4214.761 87.159 3192.577 3279.735 127.598 4465.099 4592.697

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

APU6DCUSP1

Between Groups Within Groups Total

Mean Square 14.453 32.798 63.916 54.854 22.721 27.799 65.286 51.052 43.579 39.907 63.799 55.814

F .441

Sig. .645

APANTFOP1

Between Groups Within Groups Total

1.165

.317

APU6APEX1

Between Groups Within Groups Total

.817

.445

APL6APEX1

Between Groups Within Groups Total

1.279

.284

APL6TIP1

Between Groups Within Groups Total

1.092

.340

APU1TIP1

Between Groups Within Groups Total

1.143

.324

103

Table A.11 Pretreatment Vertical Dental Measures: Descriptive Statistics

Landmark VU6DCUSP1 Group 1.00 2.00 3.00 Total VANTFOP1 1.00 2.00 3.00 Total VU6APEX1 1.00 2.00 3.00 Total VL6APEX1 1.00 2.00 3.00 Total VU6TIP1 1.00 2.00 3.00 Total VL6TIP1 1.00 2.00 3.00 Total VU1TIP1 1.00 2.00 3.00 Total VU1APEX1 1.00 2.00 3.00 Total VL1TIP1 1.00 2.00 3.00 Total VL1APEX1 1.00 2.00 3.00 Total N 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 66.1714 67.5276 67.8091 67.2964 76.8190 77.4966 77.7667 77.4325 48.1190 49.3586 49.7667 49.2072 89.0095 89.3000 89.6576 89.3687 68.0810 69.5828 69.8697 69.3169 68.2619 69.9448 70.0606 69.5651 76.5048 77.5345 77.3576 77.2036 49.2714 51.6310 51.4848 50.9759 72.8619 74.2448 74.0030 73.7988 92.7238 93.6241 92.8667 93.0952 Std. Deviation 5.75935 5.98301 4.53296 5.36478 6.02400 5.92353 5.07202 5.56904 5.06178 4.94264 3.40070 4.42057 6.72398 6.35756 5.58570 6.08873 5.74279 5.53954 4.56505 5.21477 5.90995 5.70993 4.52569 5.31313 5.93628 5.81392 4.75434 5.39734 5.49819 5.37202 4.61892 5.15297 6.54358 6.64189 4.94580 5.94683 7.09767 6.82331 5.51048 6.33956 Std. Error 1.25679 1.11102 .78909 .58886 1.31455 1.09997 .88293 .61128 1.10457 .91782 .59199 .48522 1.46729 1.18057 .97235 .66833 1.25318 1.02867 .79467 .57240 1.28966 1.06031 .78782 .58319 1.29540 1.07962 .82762 .59244 1.19980 .99756 .80405 .56561 1.42793 1.23337 .86095 .65275 1.54884 1.26706 .95925 .69586

104

Table A.11 (Continued)

Landmark APU6DCUSP1 Group 1.00 2.00 3.00 Total N 21 29 33 83 Mean 31.9143 31.1517 30.4242 31.0554 Std. Deviation 5.63784 5.92119 5.60820 5.68778 Std. Error 1.23028 1.09954 .97626 .62431

Table A.12 ANOVA for Pretreatment Vertical Dental Measures

Sum of Squares 36.801 2323.228 2360.029 11.707 2531.455 2543.162 35.860 1566.536 1602.396 5.600 3034.359 3039.959 44.213 2185.683 2229.896 47.949 2266.860 2314.809 14.213 2374.556 2388.769 82.004 2095.347 2177.352 25.579 2874.331 2899.910 12.734 3282.845 3295.578 28.906 2623.859 2652.765

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VU6DCUSP1

Between Groups Within Groups Total

Mean Square 18.400 29.040 5.853 31.643 17.930 19.582 2.800 37.929 22.106 27.321 23.974 28.336 7.107 29.682 41.002 26.192 12.789 35.929 6.367 41.036 14.453 32.798

F .634

Sig. .533

VANTFOP1

Between Groups Within Groups Total

.185

.831

VU6APEX1

Between Groups Within Groups Total

.916

.404

VL6APEX1

Between Groups Within Groups Total

.074

.929

VU6TIP1

Between Groups Within Groups Total

.809

.449

VL6TIP1

Between Groups Within Groups Total

.846

.433

VU1TIP1

Between Groups Within Groups Total

.239

.788

VU1APEX1

Between Groups Within Groups Total

1.565

.215

VL1TIP1

Between Groups Within Groups Total

.356

.702

VL1APEX1

Between Groups Within Groups Total

.155

.857

APU6DCUSP1

Between Groups Within Groups Total

.441

.645

105

Table A.13 Pretreatment Measures for Non-significant Horizontal Soft Tissue Landmarks: Descriptive Statistics
N APPRN1 1.00 2.00 3.00 Total APSBN1 1.00 2.00 3.00 Total APLABSU1 1.00 2.00 3.00 Total APSTMSU1 1.00 2.00 3.00 Total APSTINF1 1.00 2.00 3.00 Total APLABIN1 1.00 2.00 3.00 Total APPOG1 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 99.1286 101.4414 98.8152 99.8120 85.7286 86.7207 84.3636 85.5325 90.4857 88.3931 86.1273 88.0217 82.9190 80.2414 78.3091 80.1506 82.2238 79.9517 77.9273 79.7217 86.3000 83.8586 81.6061 83.5807 75.0667 73.7966 72.4697 73.5904 Std. Deviation 4.72400 5.45832 6.11331 5.62664 5.00591 4.95280 5.73971 5.32949 8.64010 6.62403 7.14568 7.49429 8.88328 7.02569 6.94007 7.63074 9.53566 7.13516 7.01228 7.85295 10.49486 7.98411 7.71889 8.68172 9.85507 8.41879 9.60753 9.21900 Std. Error 1.03086 1.01358 1.06419 .61760 1.09238 .91971 .99916 .58499 1.88542 1.23005 1.24390 .82261 1.93849 1.30464 1.20811 .83758 2.08085 1.32497 1.22068 .86197 2.29017 1.48261 1.34369 .95294 2.15055 1.56333 1.67246 1.01192

106

Table A.14 ANOVA for Non-significant Pretreatment Horizontal Measures

Sum of Squares 119.592 2476.456 2596.048 86.835 2242.247 2329.082 249.931 4355.550 4605.481 273.097 4501.610 4774.707 239.265 4817.576 5056.841 286.200 5894.329 6180.529 88.446 6880.726 6969.172

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

APPRN1

Between Groups Within Groups Total

Mean Square 59.796 30.956 43.418 28.028 124.966 54.444 136.549 56.270 119.633 60.220 143.100 73.679 44.223 86.009

F 1.932

Sig. .152

APSBN1

Between Groups Within Groups Total

1.549

.219

APLABSU1

Between Groups Within Groups Total

2.295

.107

APSTMSU1

Between Groups Within Groups Total

2.427

.095

APSTINF1

Between Groups Within Groups Total

1.987

.144

APLABIN1

Between Groups Within Groups Total

1.942

.150

APPOG1

Between Groups Within Groups Total

.514

.600

107

Table A.15 Pretreatment Vertical Measures for Soft Tissue Landmarks: Descriptive Statistics
N VPRN1 1.00 2.00 3.00 Total VSBN1 1.00 2.00 3.00 Total VLABSU1 1.00 2.00 3.00 Total VSTMSU1 1.00 2.00 3.00 Total VSTINF1 1.00 2.00 3.00 Total VLABIN1 1.00 2.00 3.00 Total VPOG1 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 37.4381 40.1310 40.7030 39.6771 50.5952 53.1069 52.4242 52.2000 64.6952 67.1586 66.9152 66.4386 73.4619 74.8207 74.0848 74.1843 74.6619 75.8034 75.6121 75.4386 82.6143 83.3828 83.0394 83.0518 106.2333 108.1103 104.9970 106.3976 Std. Deviation 4.44032 5.91488 5.08604 5.35073 4.08295 4.81426 4.90510 4.72652 5.44495 6.56166 4.84033 5.66824 6.72588 6.05837 5.00132 5.79730 6.62982 5.66969 5.23311 5.70945 9.11210 6.53917 6.40561 7.13812 8.96874 9.40351 7.09976 8.44500 Std. Error .96896 1.09837 .88537 .58732 .89097 .89399 .85387 .51880 1.18819 1.21847 .84259 .62217 1.46771 1.12501 .87062 .63634 1.44674 1.05283 .91097 .62669 1.98842 1.21429 1.11507 .78351 1.95714 1.74619 1.23591 .92696

108

Table A.16 ANOVA for Pretreatment Vertical for Soft Tissue Landmarks
Sum of Squares 145.985 2201.701 2347.687 79.591 1752.289 1831.880 86.354 2548.222 2634.577 23.030 2732.880 2755.910 17.522 2655.494 2673.017 7.201 4170.926 4178.127 150.376 5697.703 5848.080

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VPRN1

Between Groups Within Groups Total

Mean Square 72.993 27.521 39.796 21.904 43.177 31.853 11.515 34.161 8.761 33.194 3.601 52.137 75.188 71.221

F 2.652

Sig. .077

VSBN1

Between Groups Within Groups Total

1.817

.169

VLABSU1

Between Groups Within Groups Total

1.356

.264

VSTMSU1

Between Groups Within Groups Total

.337

.715

VSTINF1

Between Groups Within Groups Total

.264

.769

VLABIN1

Between Groups Within Groups Total

.069

.933

VPOG1

Between Groups Within Groups Total

1.056

.353

109

Appendix B:

Non-significant Post Treatment Data

Table B.1 Post-Treatment Non-Significant Horizontal Mandibular Measures: Descriptive Statistics

N APBPT2 1.00 2.00 3.00 Total APPOG2 1.00 2.00 3.00 Total APGN2 1.00 2.00 3.00 Total APME2 1.00 2.00 3.00 Total APGO2 1.00 2.00 3.00 Total APCO2 1.00 2.00 3.00 Total 20 29 33 82 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83

Mean 60.9350 59.7207 55.5909 58.3549 59.8810 59.3759 55.3364 57.8976 56.4238 56.4414 51.9364 54.6458 51.8095 51.2828 46.8788 49.6651 -15.1190 -14.4897 -16.4030 -15.4096 -20.8905 -21.0069 -20.6545 -20.8373

Std. Deviation 8.89673 8.00211 9.41041 9.00615 10.18571 8.57441 10.14254 9.74547 10.38335 9.05793 10.79363 10.23134 10.35750 9.92033 11.27691 10.70626 7.43442 5.36119 5.84826 6.11231 3.74725 3.63789 2.97291 3.37894

Std. Error 1.98937 1.48596 1.63814 .99456 2.22270 1.59223 1.76559 1.06970 2.26583 1.68202 1.87893 1.12304 2.26019 1.84216 1.96306 1.17516 1.62232 .99555 1.01805 .67091 .81772 .67554 .51752 .37089

110

Table B.2 ANOVA for Post-Treatment Mandibular Horizontal Measures

Sum of Squares 439.343 6130.620 6569.963 362.458 7425.422 7787.880 402.141 8181.645 8583.786 428.654 8970.515 9399.169 58.883 3004.669 3063.552 1.996 934.219 936.214

df 2 79 81 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

APBPT2

Between Groups Within Groups Total

Mean Square 219.671 77.603 181.229 92.818 201.071 102.271 214.327 112.131 29.442 37.558 .998 11.678

F 2.831

Sig. .065

APPOG2

Between Groups Within Groups Total

1.953

.149

APGN2

Between Groups Within Groups Total

1.966

.147

APME2

Between Groups Within Groups Total

1.911

.155

APGO2

Between Groups Within Groups Total

.784

.460

APCO2

Between Groups Within Groups Total

.085

.918

111

Table B.3 Post-Treatment Non-Significant Vertical Mandibular Measures: Descriptive Statistics

N VBPT2 1.00 2.00 3.00 Total VPOG2 1.00 2.00 3.00 Total VGN2 1.00 2.00 3.00 Total VME2 1.00 2.00 3.00 Total VGO2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 101.0381 100.4276 99.8061 100.3349 116.8333 112.2241 114.1424 114.1530 120.5810 118.4690 119.3152 119.3398 121.3429 120.2000 120.1485 120.4687 78.6714 78.1759 78.4152 78.3964 Std. Deviation 10.46535 8.00548 6.65277 8.13086 11.22891 8.10871 7.22176 8.75861 11.04272 8.21671 6.98946 8.51604 10.50155 7.98199 6.70854 8.15345 8.89203 6.42360 7.06864 7.27393 Std. Error 2.28373 1.48658 1.15810 .89248 2.45035 1.50575 1.25715 .96138 2.40972 1.52581 1.21671 .93476 2.29163 1.48222 1.16781 .89496 1.94040 1.19283 1.23049 .79842

112

Table B.4 ANOVA for Non-Significant Post-Treatment Vertical Mandibular Measures

Sum of Squares 19.862 5401.226 5421.089 258.766 6031.720 6290.487 54.362 5892.517 5946.879 21.525 5429.734 5451.259 3.011 4335.618 4338.629

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VBPT2

Between Groups Within Groups Total

Mean Square 9.931 67.515 129.383 75.397 27.181 73.656 10.762 67.872 1.505 54.195

F .147

Sig. .863

VPOG2

Between Groups Within Groups Total

1.716

.186

VGN2

Between Groups Within Groups Total

.369

.693

VME2

Between Groups Within Groups Total

.159

.854

VGO2

Between Groups Within Groups Total

.028

.973

113

Table B.5 Post-Treatment Horizontal Maxillary Measures: Statistics

N APANS2 1.00 2.00 3.00 Total APPNS2 1.00 2.00 3.00 Total APAPT2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 Mean 69.8714 71.1207 69.8030 70.2807 16.9762 15.3586 14.6212 15.4747 67.5667 67.6759 65.9576 66.9651 Std. Deviation 5.53698 5.68321 6.23987 5.83826 3.69282 5.07779 4.79269 4.68716 5.84092 5.89053 6.03961 5.92318

Descriptive

Std. Error 1.20827 1.05535 1.08622 .64083 .80584 .94292 .83430 .51448 1.27459 1.09384 1.05136 .65015

Table B.6 ANOVA for Post-Treatment Horizontal Maxillary Measures

N APANS2 1.00 2.00 3.00 Total APPNS2 1.00 2.00 3.00 Total APAPT2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 Mean 69.8714 71.1207 69.8030 70.2807 16.9762 15.3586 14.6212 15.4747 67.5667 67.6759 65.9576 66.9651 Std. Deviation 5.53698 5.68321 6.23987 5.83826 3.69282 5.07779 4.79269 4.68716 5.84092 5.89053 6.03961 5.92318 Std. Error 1.20827 1.05535 1.08622 .64083 .80584 .94292 .83430 .51448 1.27459 1.09384 1.05136 .65015

114

Table B.7 Post Treatment Vertical Maxillary Measures: Statistics

N VANS2 1.00 2.00 3.00 Total VPNS2 1.00 2.00 3.00 Total VAPT2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 Mean 50.6619 50.9931 50.8697 50.8602 47.6619 46.5276 46.9121 46.9675 54.3952 55.1517 55.0667 54.9265 Std. Deviation 4.08821 3.50916 4.16792 3.88289 4.59124 3.27642 3.82865 3.83673 4.36182 3.68856 4.08631 3.98754

Descriptive

Std. Error .89212 .65164 .72554 .42620 1.00189 .60842 .66648 .42114 .95183 .68495 .71133 .43769

Table B.8 ANOVA for Post-Treatment Vertical Maxillary Measures

Sum of Squares 1.341 1234.958 1236.299 15.840 1191.243 1207.082 8.046 1295.795 1303.842

df 2 80 82 2 80 82 2 80 82

VANS2

Between Groups Within Groups Total

Mean Square .670 15.437 7.920 14.891 4.023 16.197

F .043

Sig. .958

VPNS2

Between Groups Within Groups Total

.532

.590

VAPT2

Between Groups Within Groups Total

.248

.781

115

Table B.9 Non-Significant Post-Treatment Horizontal Soft Tissue Measures

N APPRN2 1.00 2.00 3.00 Total APSBN2 1.00 2.00 3.00 Total APPOG2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 Mean 102.4810 103.0793 99.3212 101.4337 87.0762 87.0207 83.5636 85.6602 75.3333 72.8483 69.3909 72.1024 Std. Deviation 6.33653 6.75470 6.74939 6.79591 5.70578 5.91574 6.99526 6.47483 9.51212 9.25398 10.77284 10.12069 Std. Error 1.38274 1.25432 1.17492 .74595 1.24510 1.09853 1.21772 .71070 2.07571 1.71842 1.87531 1.11089

Table B.10 ANOVA for Non-Significant Post Treatment Horizontal Soft Tissue Measures
Sum of Squares 248.830 3538.295 3787.126 240.837 3196.882 3437.719 477.973 7921.146 8399.120

df 2 80 82 2 80 82 2 80 82

APPRN2

Between Groups Within Groups Total

Mean Square 124.415 44.229 120.418 39.961 238.987 99.014

F 2.813

Sig. .066

APSBN2

Between Groups Within Groups Total

3.013

.055

APPOG2

Between Groups Within Groups Total

2.414

.096

116

Table B.11 Post-Treatment Vertical Soft Tissue Measures: Statistics

N VPRN1 1.00 2.00 3.00 Total VSBN1 1.00 2.00 3.00 Total VLABSU1 1.00 2.00 3.00 Total VSTMSU1 1.00 2.00 3.00 Total VSTINF1 1.00 2.00 3.00 Total VLABIN1 1.00 2.00 3.00 Total VPOG1 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 37.4381 40.1310 40.7030 39.6771 50.5952 53.1069 52.4242 52.2000 64.6952 67.1586 66.9152 66.4386 73.4619 74.8207 74.0848 74.1843 74.6619 75.8034 75.6121 75.4386 82.6143 83.3828 83.0394 83.0518 106.2333 108.1103 104.9970 106.3976 Std. Deviation 4.44032 5.91488 5.08604 5.35073 4.08295 4.81426 4.90510 4.72652 5.44495 6.56166 4.84033 5.66824 6.72588 6.05837 5.00132 5.79730 6.62982 5.66969 5.23311 5.70945 9.11210 6.53917 6.40561 7.13812 8.96874 9.40351 7.09976 8.44500

Descriptive

Std. Error .96896 1.09837 .88537 .58732 .89097 .89399 .85387 .51880 1.18819 1.21847 .84259 .62217 1.46771 1.12501 .87062 .63634 1.44674 1.05283 .91097 .62669 1.98842 1.21429 1.11507 .78351 1.95714 1.74619 1.23591 .92696

117

Table B.12 ANOVA for Post-treatment Vertical Measures for Soft Tissue Landmarks
Sum of Squares 145.985 2201.701 2347.687 79.591 1752.289 1831.880 86.354 2548.222 2634.577 23.030 2732.880 2755.910 17.522 2655.494 2673.017 7.201 4170.926 4178.127 150.376 5697.703 5848.080

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VPRN1

Between Groups Within Groups Total

Mean Square 72.993 27.521 39.796 21.904 43.177 31.853 11.515 34.161 8.761 33.194 3.601 52.137 75.188 71.221

F 2.652

Sig. .077

VSBN1

Between Groups Within Groups Total

1.817

.169

VLABSU1

Between Groups Within Groups Total

1.356

.264

VSTMSU1

Between Groups Within Groups Total

.337

.715

VSTINF1

Between Groups Within Groups Total

.264

.769

VLABIN1

Between Groups Within Groups Total

.069

.933

VPOG1

Between Groups Within Groups Total

1.056

.353

118

Table B.13 Post-treatment Horizontal Dental Measures: Statistics

N APU6DCUSP2 1.00 2.00 3.00 Total APANTFOP2 1.00 2.00 3.00 Total APU6APEX2 1.00 2.00 3.00 Total APL6APEX2 1.00 2.00 3.00 Total APL6TIP2 1.00 2.00 3.00 Total APU1TIP2 1.00 2.00 3.00 Total APU1APEX2 1.00 2.00 3.00 Total APL1TIP2 1.00 2.00 3.00 Total APL1APEX2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 32.1667 31.7414 29.6455 31.0157 73.3190 71.4517 68.5333 70.7639 44.9905 43.7379 41.8515 43.3048 34.0571 33.3828 30.6091 32.4506 43.3143 42.2414 39.9727 41.6108 73.2381 71.1690 68.4182 70.5988 62.4286 62.1276 60.0848 61.3916 70.8286 69.0966 65.8545 68.2458 56.3619 54.4276 51.0303 53.5663 Std. Deviation 6.27275 6.04380 5.80108 6.04016 8.07172 6.46720 8.27023 7.79137 5.20537 6.10248 5.40758 5.69038 7.70302 7.57265 7.69766 7.71428 6.33208 6.02213 6.66681 6.43983 8.05341 6.79170 8.09955 7.80918 5.82024 5.53172 5.81711 5.75070 8.21238 6.53313 7.85136 7.70360 9.29481 7.33007 9.13809 8.76685

Descriptive

Std. Error 1.36883 1.12231 1.00984 .66299 1.76139 1.20093 1.43966 .85521 1.13591 1.13320 .94134 .62460 1.68094 1.40621 1.33999 .84675 1.38177 1.11828 1.16054 .70686 1.75740 1.26119 1.40995 .85717 1.27008 1.02721 1.01263 .63122 1.79209 1.21317 1.36675 .84558 2.02829 1.36116 1.59074 .96229

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Table B.14 ANOVA for Post-Treatment Horizontal Dental Measures

Sum of Squares 105.051 2886.599 2991.650 315.013 4662.838 4977.852 134.809 2520.389 2655.198 191.307 4688.520 4879.827 161.019 3239.642 3400.660 312.629 4688.001 5000.630 94.641 2617.143 2711.784 349.772 4516.554 4866.326 397.868 5904.457 6302.326

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

APU6DCUSP2

Between Groups Within Groups Total

Mean Square 52.525 36.082 157.507 58.285 67.405 31.505 95.654 58.607 80.509 40.496 156.315 58.600 47.320 32.714 174.886 56.457 198.934 73.806

F 1.456

Sig. .239

APANTFOP2

Between Groups Within Groups Total

2.702

.073

APU6APEX2

Between Groups Within Groups Total

2.139

.124

APL6APEX2

Between Groups Within Groups Total

1.632

.202

APL6TIP2

Between Groups Within Groups Total

1.988

.144

APU1TIP2

Between Groups Within Groups Total

2.667

.076

APU1APEX2

Between Groups Within Groups Total

1.446

.241

APL1TIP2

Between Groups Within Groups Total

3.098

.051

APL1APEX2

Between Groups Within Groups Total

2.695

.074

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Table B.15 Post-Treatment Vertical Dental Measures: Statistics

N VU6DCUSP2 1.00 2.00 3.00 Total VANTFOP2 1.00 2.00 3.00 Total VU6APEX2 1.00 2.00 3.00 Total VL6APEX2 1.00 2.00 3.00 Total VU6TIP2 1.00 2.00 3.00 Total VL6TIP2 1.00 2.00 3.00 Total VU1TIP2 1.00 2.00 3.00 Total VU1APEX2 1.00 2.00 3.00 Total VL1TIP2 1.00 2.00 3.00 Total VL1APEX2 1.00 2.00 3.00 Total 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 21 29 33 83 Mean 71.7381 71.5069 71.0909 71.4000 82.1524 80.5793 82.2818 81.6542 53.5000 53.1345 53.6485 53.4313 95.4857 93.7966 93.6636 94.1711 74.3286 73.6690 73.5909 73.8048 74.9143 74.0828 74.3121 74.3843 81.8476 81.2172 82.0909 81.7241 55.3381 55.5517 57.5879 56.3072 79.9762 79.7690 80.1758 79.9831 99.6381 98.3862 97.5273 98.3614 Std. Deviation 6.82975 5.29305 4.49481 5.37583 6.11953 5.73127 5.14177 5.59445 6.21651 5.82803 4.38906 5.34721 7.60752 5.86092 5.61103 6.22312 6.51591 5.37096 4.51362 5.31519 6.61901 5.48433 4.53299 5.39269 6.46256 5.20364 5.01955 5.42347 5.54125 4.35313 4.85391 4.92509 6.43358 5.17060 4.57705 5.23745 7.82461 6.54658 5.54258 6.50024

Descriptive

Std. Error 1.49037 .98289 .78245 .59007 1.33539 1.06427 .89507 .61407 1.35655 1.08224 .76404 .58693 1.66010 1.08834 .97675 .68308 1.42189 .99736 .78572 .58342 1.44439 1.01842 .78909 .59192 1.41025 .96629 .87379 .59530 1.20920 .80836 .84496 .54060 1.40392 .96016 .79676 .57489 1.70747 1.21567 .96484 .71349

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Table B.16 ANOVA for Post-Treatment Vertical Dental Measures

Sum of Squares 5.885 2363.875 2369.760 51.717 2514.709 2566.426 4.211 2340.388 2344.599 48.859 3126.772 3175.631 7.806 2308.792 2316.598 8.707 2375.942 2384.650 12.211 2399.741 2411.952 90.399 1898.637 1989.036 2.556 2246.781 2249.336 57.207 3407.549 3464.757

df 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82 2 80 82

VU6DCUSP2

Between Groups Within Groups Total

Mean Square 2.942 29.548 25.858 31.434 2.105 29.255 24.429 39.085 3.903 28.860 4.354 29.699 6.105 29.997 45.199 23.733 1.278 28.085 28.604 42.594

F .100

Sig. .905

VANTFOP2

Between Groups Within Groups Total

.823

.443

VU6APEX2

Between Groups Within Groups Total

.072

.931

VL6APEX2

Between Groups Within Groups Total

.625

.538

VU6TIP2

Between Groups Within Groups Total

.135

.874

VL6TIP2

Between Groups Within Groups Total

.147

.864

VU1TIP2

Between Groups Within Groups Total

.204

.816

VU1APEX2

Between Groups Within Groups Total

1.904

.156

VL1TIP2

Between Groups Within Groups Total

.045

.956

VL1APEX2

Between Groups Within Groups Total

.672

.514

122

Literature Cited 1. Ker AJ, Chan R, Fields HW, Beck M, Rosenstiel S. Esthetics and smile characteristics from the layperson's perspective: a computer-based survey study. J Am Dent Assoc. 2008;139(10):1318-1327. 2. Van der Geld P, Oosterveld P, Van Heck G, KuijpersJagtman AM. Smile attractiveness. Self-perception and influence on personality. Angle Orthod. 2007;77(5):759765. 3. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992;62(2):91-100. 4. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984;51(1):24-28. 5. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39(5):502-504. 6. Van der Geld PA, van Waas MA. [The smile line, a literature search]. Ned Tijdschr Tandheelkd. 2003;110(9):350-354. 7. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ. The long face syndrome: vertical maxillary excess. Am J Orthod. Dentofacial Orthop. 1976;70(4):398-408. 8. Singer R. A study of the morphologic, treatment and esthetic aspects of gingival display. American Journal of Orthod. Dentofacial Orthop. 1974;65:435-436. 9. Mackley RJ. An Evaluation of smiles before and after orthodontic treatment. The Angle Orthod. 1993;63(3):183189.

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VITA AUCTORIS Jessica H. Cox was born in Pocahontas, Arkansas on October 24, 1981 to Danny B. Holt, M.D. and Sandra F. Holt. She is the second of four children. She grew up in Pocahontas, Arkansas and graduated from Pocahontas High School in May of 2000. She attended the

University of Mississippi in Oxford, Mississippi where she obtained a Bachelor of Science degree in 2004. She obtained her Doctor of Dental Surgery degree from the University of Tennessee in May of 2007. In June of that same year, she

began her postgraduate orthodontic residency at Saint Louis University, Center for Advanced Dental Education, where she expects to receive a Masters of Science in Dentistry in Orthodontics in January 2010. Jessica met her husband, Wynne, while attending the University of Mississippi. 2006. They were married on June 17,

Upon graduation, they plan to move to Hernando,

Mississippi where Jessica will start a private orthodontic practice.

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