CASE REPORT

Severe high angle Class II Division 1 malocclusion with vertical

maxillary excess and gummy smile: A case report
M. Redlich, DMD, MSc,a Z. Mazor, DMD,b and N. Brezniak, MD, DMD, MSDc
Jerusalem and Tel-Aviv, Israel
Severe Class II Division 1 malocclusion with vertical maxillary excess and gummy smiles can be treated in
several ways. Early orthodontic treatment with vertical control may decrease the malocclusion as well as
improve the appearance. In severe cases, orthognathic surgery might be the optimal solution. The following
case report describes a patient with a severe gummy smile, where the final esthetic improvement was
achieved by using a periodontal procedure after orthodontic treatment. (Am J Orthod Dentofacial Orthop
1999;116:317-20)

HISTORY AND EXAMINATION

An 8-year-5-month-old white female was referred

by her dentist for evaluation. Clinical examination
showed a patient with a facial pattern typical for a
mouth breather, with a severe gummy smile (Fig 1A),
short upper lip, mandibular retrognathism, and
increased lower facial height. Dental examination
revealed an Angle Class II Division 1 malocclusion
with incomplete occlusion in the early mixed dentition,
posterior cross bite, and a narrow high vault (Fig 1B).
Oral hygiene was average, and the gingiva of the maxillary complex was inflamed.
CEPHALOMETRIC ANALYSIS (FIG 2)

All vertical parameters substantiated the existence

of a vertical problem: lower facial height to total facial
height (60%), posterior facial height to total facial
height (54%), mandibular plane to FH (35), mandibular plane to S-N (43), and upper lip length (17 mm)
with incision-stomion of 12 mm. The Class II relationship was due to the combination of mild maxillary
prognathism with mild mandibular retrognathism.
PLAN OF TREATMENT

The malocclusion was partially a result of a mouthbreathing habit, with an underlying skeletal and dental
3-dimensional problem. Therefore, initially, the patient
was sent to the ENT physician for a medical consultation.1 There was no finding of any physical internal
aDepartment of Orthodontics, Hebrew University-Hadassah Faculty of Dental
Medicine, Jerusalem.
bPeriodontist in private practice, Tel Aviv.
cOrthodontist in private practice, Tel Aviv.
Reprint requests to: Dr Naphtali Brezniak, 3 Rav-Ashi St (#31), Tel-Aviv, Israel;
e-mail, brezniak@shani.net
Copyright 1999 by the American Association of Orthodontists.
0889-5406/99/$8.00 + 0 8/4/95471

obstruction of the nasal air pathway that might have

been the prime cause for the mouth-breathing habit.
However, it was suggested by the otolaryngologist to
orthodontically expand the maxillary arch to improve
the existing nasal airway passage.2
The skeletal and dental treatment plan was as follows. Phase I treatment included rapid maxillary
expansion, high pull headgear in conjunction with a
chin-cap to control the transverse, vertical, and anterior-posterior growth.3 Myofunctional therapy was prescribed through the entire treatment.4 The goals of this
phase were to improve the skeletal dental and soft tissue relations and prepare the patient for Phase II treatment with a better starting point. The parents were
aware of limitations of the orthodontic treatment alone
and of the fact that orthognathic surgery could not be
ruled out at the end of growth.
PROGRESS OF TREATMENT

The maxillary first molars were banded with a

modified Hyrax appliance. The patient was instructed
to open the screw once a day. The expansion went well
for 2 months. However, because of appliance palatal
impingement, the Hyrax appliance was replaced with a
removable plate with an expansion screw to first
improve and later hold the achieved expansion. The
high pull headgear in conjunction with a chin-cap were
delivered after stabilization of the expansion. No fixed
appliances were used during Phase I treatment, which
lasted 14 months. The 3-dimensional Phase I goals
were achieved, and significant improvement was
noticed. The gummy smile slightly decreased (Fig 3).
During the period between Phase I and Phase II, which
lasted about 2 years, the patient spent 10-12 hours a
day wearing the high pull headgear and chin-cap and
wore an upper retainer full time.
317

318 Redlich, Mazor, and Brezniak

American Journal of Orthodontics and Dentofacial Orthopedics

September 1999

A
Fig 3. Postphase I treatment: frontal view demonstrates
a slight improvement of the gummy smile.

B
Fig 1. Pretreatment photographs. A, Frontal view
demonstrates gummy smile; B, intraoral view demonstrates posterior cross-bite.
Fig 4. Intraoral view before the periodontal surgery.

Fig 2. Cephalometric tracing of the pretreatment lateral

cephalogram.

Phase II treatment goals were to improve anteriorposterior dental relationships and the vertical skeletal
and dental relationships. In addition, orthognathic
surgery to diminish the gummy smile and improve
skeletal relations was suggested. However, the parents
rejected the surgery and said they preferred a more
conservative treatment.
The patient was fully bonded at the age of 13 years
10 months, and the upper arch was intruded with highpull headgear with Burstone type intrusion mechanics.5 Phase II treatment lasted 12 months.
Because the parents were not satisfied with the
patients smile, they agreed to the suggestion of referring the patient to the periodontist to lengthen the
anatomic crown that was covered by excessive gingival
tissue. This procedure took place after removal of the
fixed appliances, and the results are discussed later
(Figs 4-6).

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 116, Number 3

Fig 5. Surgical procedure demonstrates amount of

removed tissue.

Redlich, Mazor, and Brezniak 319

Fig 6. Intraoral view 1 month after periodontal surgery.

Fig 7. Cephalometric superimposition: Black, initial (8:5); blue, initial phase II (13:0); red, end of phase II (14:0).
DISCUSSION

The term gummy smile is well known to the dental community and especially to orthodontists. Most of
the time, some exposure of the gums during smile is
more than acceptable. However, when excessive
amount of gingival tissue is exposed during smiling or
when the lips are at rest, the esthetic problem is apparent.
The reasons for a gummy smile might be: excessive

maxillary vertical growth, short upper lip, incomplete

anatomic crown exposure, and combinations of these
factors. Usually, mouth breathing can exacerbate this
condition.
This patient demonstrated a gummy smile even at
rest position when she first came to the clinic at age 8
years 5 months. Usually, the vertical growth of the lips
as well as passive tooth eruption might improve the
appearance. However, in this case, because all 3 aforementioned etiologic factors were involved, in conjunc-

320 Redlich, Mazor, and Brezniak

Table I. Serial

American Journal of Orthodontics and Dentofacial Orthopedics

September 1999

cephalometric parameters
Initial phase I* Initial phase II* End of phase II*

SNA
A to Na Perp
SNB
ANB
WITS
FMA
Go-Gn to SN
LFH/TFH
PFH/TFH
U1 to SN
L1 to NB
Upper lip length
Incision-stomion

85
2
77
8
3
35
43
60
54
105
98
17
12

85
4
77
8
3
32
40
59
59
106
97
19
9

85
2
78
7
4
31
39
58
59
109
100
22
6

*See Fig 7: initial phase I-black; initial phase II-blue; end of

phase II-red.

tion with mouth breathing and a Class II Division 1

malocclusion with a severe transverse problem, Phase I
treatment was recommended.6
The serial superimposition of the headplates (Table
I and Fig 7) demonstrates that the high pull headgear in
conjunction to the chin-cap and favorable growth did
decrease the mandibular plane by 3, and slightly
improved the anterior and posterior vertical relations.
The lip grew from 17 mm (age 8 years 5 months) to 22
mm (age 14), and incision stomion decreased from 12
to 6 mm. Three millimeters of upper incisors intrusion
along the long tooth axis was also achieved. This intrusion is partly responsible for the excessive gingival tissue in the upper incisor area at the end of the orthodontic treatment.
After Phase II treatment and the parents rejection
of orthognathic surgery, the procedure of anatomic
crown lengthening was suggested and performed.7,8
Lengthening the crowns, thus reducing the gingival
exposure, causes an alteration of crown to marginal tissue ratio, in favor of the teeth. Ideally, the smile should
expose minimal gingiva. In order to achieve this goal,
the anatomic crowns should be fully exposed. Precise
determination of the location of the cementoenamel
junction before the periodontal surgery and precise
placement of the incisors are necessary in order to
achieve this goal. In this case, the surgical gingivec-

Fig 8. The smile after orthodontic periodontic treatment.

tomy procedure resulted in a significant improvement

in esthetics (Fig 8).
CONCLUSION

This severe high angle Class II Division 1 malocclusion with vertical maxillary excess and gummy smile
case report demonstrates the need for understanding:
growth and development, treatment timing, orthodontic
treatment procedures, and interdisciplinary dentistry.
Nevertheless, without patient cooperation the treatment
success would, in this case, not be the same.
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2. Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture.
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3. Majourau A, Nanda R. biomechanical basis of vertical dimension control during rapid
palatal expansion therapy. Am J Orthod Dentofacial Orthop 1994;106:322-8.
4. Ingervall B, Eliasson GB. Effect of lip training in children with short upper lip. Angle
Orthod 1982;52:222-33.
5. Burstone CJ. Deep overbite correction by intrusion. Am J Orthod 1977;72:1-22.
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1995;107:239-44.
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