Orthotown May 2020 - 37

there are many courses, meetings and
other continuing education opportunities
that allow orthodontists to include these
adjuncts in their armamentaria. Because
pressures from DIY companies and general
providers providing basic orthodontic services
are increasingly prevalent, this knowledge
will help us differentiate ourselves in this
competitive market.

Case study: Introduction
A 13-year-old patient presented with mild
upper and lower crowding, and her family
desired an aesthetic treatment alternative.
A clinical exam revealed a Class I dental
malocclusion, mild excess gingival display
on full animated smile, mild upper and
lower crowding, an overjet of 2mm and an
overbite of 2mm. Her upper lateral incisors
are on the tapered side and we discussed
the possibility of buildups/veneers, but the
family didn't view them as an aesthetic issue.
There was a minor discrepancy in the
free-gingival heights of her upper central
incisors. The zenith of her UL1 (#9) was
slightly higher than its counterpart, and
the discrepancy appeared to slightly worsen
during the course of her treatment. There
was a mild Bolton discrepancy with mild
excess in the lower arch. Her oral hygiene
was excellent, there was mild redundant
tissue around the maxillary lateral incisors,
her profile was mildly convex, and there was
no evidence of temporomandibular joint
issues. On full animation, I noticed that
she exhibited about 2-3mm of maxillary
gingival display (Figs. 1a-e).
While the family had a lot of confidence in this patient's discipline to wear
aligners, they felt better about pursuing
traditional fi xed-appliance therapy. While
treatment-planning this case, I requested a
digital rendering of the final occlusion and

noted that it would require
some mild IPR around the
lower incisors to maximize her
full, anterior coupling because
of the mild Bolton discrepancy.
The rendering did not include
the surrounding facial tissues,
but the family and I discussed
the idea of aesthetic gingival
contouring. This was brought
to their attention not only because
of the Bolton discrepancy but also
because of the very mild excess
gingival display on full smile and
the mild difference of the gingival
heights of her maxillary central
incisors.
I generally approach similar
cases by evaluating the length of
the maxillary clinical crowns where
those upper incisors lie on the smile
arc, or how they line up on the lower
lip and how much redundant tissue
masks the clinical crowns.
There are several ways to
determine whether orthodontic
intrusion or a simple gingivectomy
may be required. My aesthetic reference pivots around the 3-5mm
mark of gingival display on full
smile. Anything less than this, I
prefer to perform mild gingival
contouring. Anything greater
than 5mm, I will discuss the
advantages and disadvantages of
possible intrusion of the anterior
dentition, along with realistic
expectations. Anything greater
than 8-10mm of full gingival
display gets an orthognathic
consultation if the patient wants
to get the gingival display reduced.
This patient had shorter,

Figs. 1a-e

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