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Use of Segmented Mechanics to Achieve an

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CASE REPORT
Use of Segmented Mechanics to
Achieve an Ideal Smile Arc and
Rejuvenated Dental Appearance
ANDR WILSON MACHADO, PhD, MS, DDS
ADRIANA PEDROSA MOURA, PhD, MS, DDS
A lthough a functional occlu-
sion is always one of the
main goals of orthodontic treat-
ment, patients often seek treat-
ment for more esthetic reasons.1-4
The expectations of orthodontic
treatment are no longer restricted
to dental alignment; patients now
seek a beautiful and harmonious
smile and, more recently, facial
rejuvenation, 5-8 which they be-
lieve will improve their popular-
ity and social success.9,10
Smile attractiveness is a
subjective matter, but several ba-
sic rules seem to applyfor ex-
ample, the upper central incisors
must be symmetrical and must be
Dr. Machado is an Associate Professor, Section of Orthodontics, Dental School, Universidade
Federal da Bahia, Av. Arajo Pinho, 62, Canela, Salvador, Bahia 40110-040, Brazil; e-mail:
awmachado@gmail.com. Dr. Moura is a Professor, Department of Biomorphology, Escola
Bahiana de Medicina e Sade Pblica, Salvador.
VOLUME L NUMBER 9
displayed during the posed smile.
The change in incisor display
with aging is probably due to a
reduction in lip tone and resilien-
cy.4 Some authors also believe
there should be 1-3mm of gingi-
val display at rest, depending on
age and gender.1,4,6,11-13 The maxil-
lary incisal edges should be par-
allel to the curvature of the lower
lip, in coordination with an ideal
smile arc and proper buccal cor-
ridors.14-17 These characteristics
promote not only a harmonious
smile, but a youthful appear-
ance.16 Although photographs
have long been the standard
method for evaluating posed
Dr. Machado
2016 JCO, Inc.
smiles, the significance of incisor
display during dynamic smiling
and speech has recently been rec-
ognized, making video an impor-
tant new tool.18
In orthodontic treatment, an
ideal vertical position of the upper
incisors is generally obtained by
dental intrusion and extrusion us-
ing various techniques, including
vertical brackets, vertical elastics,
step bends, leveling and align-
ment with continuous or segment-
ed archwires, and mini-implants.17
In certain clinical situations, a
segmented-arch technique may be
effective because of its avoidance
of collateral effects.
Dr. Moura
563
Use of Segmented Mechanics to Achieve an Ideal Smile Arc

Fig. 132-year-old male patient

with Class I molar relationship,
lower anterior crowding, and over-
erupted upper canines before
treatment.

564 JCO/SEPTEMBER 2016


Diagnosis and
Treatment Plan
A 32-year-old male with
good oral hygiene presented with
the chief complaint of lower ante-
rior crowding and overerupted
upper canines, which had resulted
in reduced upper-incisor exposure
at rest and a reverse smile arc
(Fig. 1). He had previously under-
gone two years of treatment as an
adolescent with a different ortho-
dontist.
The patient had a symmet-
rical facial pattern and a straight
profile. During posed smiling,
however, there was no gingival
display and incomplete upper-
incisor exposure. The lower-
incisor crowns could be observed
at rest, but no upper incisors
were displayed, compromising
the appearance of dental and fa-
cial youth.
The patient had a Class I
malocclusion with an adequate
posterior relationship, good arch-
form, satisfactory overjet, minimal
overbite, and slight midline devia-
tion. The lower arch exhibited mi-
nor crowding; all teeth were pres-
ent, including the third molars.
The patient displayed an extreme
deviation in the esthetic zone, with
the upper central-incisor edges po-
sitioned above the canine edges.
The panoramic radiograph con-
firmed the clinical evaluation and
showed that the sinuses were nor-
mal. Cephalometric analysis indi-
cated normal sagittal and vertical
skeletal patterns.
*Trademark of 3M Unitek, Monrovia, CA;
www.3Munitek.com.
**Registered trademark of Ormco Corpo
ration, Orange, CA; www.ormco.com.
VOLUME L NUMBER 9
The overall treatment goal
was to extrude and apply buccal
crown torque to the upper incisors
to rejuvenate the dentofacial ap-
pearance and reestablish an ideal
smile arc. Functionally, the aim
was to maintain the posterior oc-
clusion and increase the overbite.
Lower-anterior crowding would
be corrected by means of inter-
proximal enamel reduction.
Four treatment options were
considered. The first was to use a
continuous-arch technique to lev-
el and align the maxillary arch.
Although this approach was the
simplest, it had two important
disadvantages. First, the extrusive
force applied to the upper anterior
teeth would also produce unwant-
ed intrusion and a greater moment
in the posterior regions, generat-
ing a counterclockwise rotation
that would modify the anteropos-
terior relationship. Second, the
continuous arch would apply forc-
es at the brackets of the upper an-
terior teeth, anterior to the center
of resistance, so that the corre-
sponding moment would be lin-
gual crown torquethe opposite
of the desired result.
The second treatment choice
was to extrude the upper incisors
by means of intermaxillary elas-
tics. Although this could have
avoided the intrusive forces in the
maxillary posterior region, it
would have required patient com-
pliance and promoted undesirable
extrusion of the lower anterior
teeth, possibly aging the patients
appearance.
The third option was to use
maxillary anterior mini-implants
as anchorage for open-coil springs
to extrude the incisors. Mini-
Machado and Moura
implants could also have been
placed in the mandibular arch for
attachment of elastics to extrude
the upper incisors. Both strategies
could have controlled the unwant-
ed side effects of the continuous-
arch technique, but would have
caused greater patient discomfort,
especially in the anterior region.
In the end, we recommend-
ed a segmented-arch technique
because it could control undesir-
able side effects in the posterior
regions while applying individual
forces and moments in the ante-
rior segment.
Treatment Progress
An .022" .025" MBT* ap-
pliance was bonded in the lower
arch, and an .016" nickel titanium
archwire was placed for leveling
and alignment. Minor interproxi-
mal enamel reduction was pro-
gressively performed in the lower
anterior region to promote proper
alignment. Three months later, an
.020" stainless steel archwire was
inserted and tied back (Fig. 2). A
similar MBT appliance was then
bonded in the maxillary arch, a
three-piece arch was placed to ex-
trude the maxillary anterior seg-
ment, and an .021" .025" heavy
stainless steel archwire was
placed passively for stabilization.
In the anterior segment, an .019"
.025" heavy stainless steel arch-
wire with extensions distal to the
center of resistance of the ante-
rior teeth (between the canines
and first premolars) was also
placed passively. An extrusion
force of 80g per side was applied
with an .017" .025" TMA** tip-
forward spring. Although an ex-
565
Use of Segmented Mechanics to Achieve an Ideal Smile Arc

trusive force was thus generated
anteriorly and an intrusive force
posteriorly, the forces were low,
minimizing the side effects as-
sociated with a counterclockwise
moment (Fig. 3). Buccal crown
torque was added because the
force was applied distal to the an-
terior segment.
After seven months of treat-
ment, the upper anterior teeth had
been extruded and buccally
torqued. The overjet and overbite
were within normal limits, the
upper-incisor vertical positioning

Fig. 2 After three months of leveling and alignment with lower .022"
.025" MBT* appliance, .020" stainless steel archwire placed and tied
back. Upper MBT appliance bonded, three-piece arch placed for ex-
trusion, and passive .021" .025" heavy stainless steel archwire placed
for stabilization. In anterior segment, passive .019" .025" heavy stain-
less steel archwire placed with extensions distal to center of resis-
tance of anterior teeth.

Fig. 3 Anterior extrusive force and posterior intrusive force associated

with counterclockwise moment and buccal crown torque.

Fig. 4 After seven months of treatment, showing improved vertical po-

sitioning of upper incisors.

566 JCO/SEPTEMBER 2016


was improved, and the facial es-
thetics were optimized (Fig. 4). A
continuous .018" stainless steel
maxillary archwire was then
placed for leveling and realign-
ment. Two months later, an .018"
.025" TMA maxillary archwire
was inserted for finishing and de-
tailing, and the upper incisors
were extruded 1mm with a gentle
stepdown bend.
Treatment was completed in
15 months. A 3-3 retainer was
bonded in the lower arch, and an
Essix*** retainer was fabricated
for the upper arch.
Treatment Results
Final records showed good
intercuspation, bilateral Class I
molar and canine relationships,
and ideal anterior overjet and
overbite (Fig. 5). The lower-ante-
rior crowding was corrected, and
the upper-incisor exposure and
smile arc were improved, rejuve-
nating the patients appearance.
The panoramic radiograph
showed proper dental positioning,
normal periodontal status, and no
signs of root resorption. Cephalo-
metric assessment substantiated
the maintenance of a Class I skel-
etal pattern and satisfactory inci-
sor positioning.
Two years after treatment,
the results remained stable, with
no relapse in the vertical position
of the upper anterior teeth (Fig. 6).
Discussion
Criteria for treatment suc-
cess sometimes diverge between
patients and orthodontists.9 While
patients tend to focus on smile
VOLUME L NUMBER 9
attractiveness, the ABO evaluates
treatment outcomes based on oc-
clusal objectives, without analyz-
ing soft- and hard-tissue relation-
ships or smile harmony.2,7 When
planning treatment in todays
practice environment, the ortho-
dontist should carefully consider
not only occlusal criteria, but also
the patients expectations.15
The relationship between
the anterior teeth and the soft tis-
sues, gingiva, and lips has long
been discussed in the litera-
ture.14,16,19,20 A recent evaluation
of close-up smile images by 60
orthodontists and 60 laypersons
concluded that extruded central
incisors were more attractive than
intruded incisors.17 There was
also a consensus that a greater
upper-incisor exposure at rest and
in smiling is a sign of youth.16,17
The amount of incisor exposure,
therefore, is one of the key factors
to be considered in choosing be-
tween intrusion and extrusion.16,21
Another esthetic guidepost is to
place the upper central-incisor
edges below the tips of the ca-
nines, thus creating a convex or
consonant smile line.18
The segmented-arch tech-
nique is advantageous in esthetic
treatment because it is able to
control tooth movement while
minimizing collateral effects.22,23
Anchor teeth need a rigid wire to
counteract any undesirable move-
ment. By contrast, in the contin-
uous-arch technique, the teeth
*Trademark of 3M Unitek, Monrovia, CA;
www.3Munitek.com.
***Registered trademark of Denstply
Raintree Essix Glenroe, Sarasota, FL; www.
essix.com.
Machado and Moura
adjacent to a malaligned tooth
often experience undesirable
movement.22
Conclusion
This article illustrates the
importance of customizing an
ideal orthodontic technique for
each specific case. Segmented
mechanics is a useful tool in pa-
tients requiring both maintenance
of posterior intercuspation and
anterior extrusion with buccal
crown torque.
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