NON- SURGICAL CORRECTION OF GUMMY SMILE AND A COMPLETE OVERBITE IN A FEMALE PATIENT WITH A CLASS II DIVISION 2 MALOCCLUSION AND A NON CONSONANT SMILE ARC BY BITE OPENING WITHOUT EXTRACTION OF PREMOLARS-A CASE REPORT

1. Professor, Dept of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Sinhgad, Pune, Maharashtra, India. 2. P.G. Student, Dept of Orthodontics and Dentofacial Orthopedics, Sinhgad Dental College and Hospital, Sinhgad, Pune, Maharashtra, India. 3. Vice Principal, Professor and HOD, Dept of Orthodontics and DentofacialOrthopedics,Balaji Dental College and Hospital, Hyderabad, Telangana, Andhra Pradesh, India. 4. Professor and H.O.D, Dept of Orthodontics and Dentofacial Orthopedics, ShriYashwanthraoChavan Dental College and Hospital, Ahmednagar, Maharashtra, India. 5. Professor, Dept of Orthodontics and Dentofacial Orthopedics, MIDSR, Latur, Maharashtra, India. 6. Associate Professor, Dept of Periodontology and Implantology, BVP Dental College and Hospital, Pune. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 April 2020 Final Accepted: 12 May 2020 Published: June 2020

This case report evaluates the management of a Gummy smile and complete deep overbite in a 17 year old female patient with an unaesthetic smile. She showed presence of crowding in the upper and lower anterior region, however the case was treated without extraction of premolars. The complete deep bite was corrected non surgically merely by employing simple mechanics with the help of Fixed Orthodontic Mechanotherapy. Following fixed orthodontic treatment marked improvement in patient's smile, facial profile and lip competence were achieved and there was a remarkable increase in the patient's confidence and quality of life.The profile changes and treatment results were demonstrated with proper case selection and good patient cooperation with Fixed appliance therapy. This case was treated in a non surgical manner and without any need for extractions. 958 caused by several of these factors.This case presents the correction of a gummy smile in a 17 year old female patient with an unaesthetic smile. She had a Class II Division 2 incisor relationship and a complete deep bite. She also showed presence of crowding in the upper and lower anterior region, however the case was continued and completed without the need for extractions of premolars.

Case Report: Extra-oral examination:
A 17 year old female patient presented with the chief complaint of irregular and crowded upper and lower front teeth and also excessive show of gums on smiing. On Extraoral examination, the patient had a convex to Orthognathic facial profile,grossly symmetrical face on both sides, competent lips ,deep mentolabial sulcus and an average Nasolabial Angle , a Leptoprosopic facial form, Dolicocephalic head form, Average width of nose and mouth, minimal buccal corridor space, anon consonant smile arc and slightly posterior divergence of face . The patient had no relevant prenatal, natal, postnatal history or a family history.On smiling, there was complete show of maxillary anterior teeth with show of upper gums. However, mandibular teeth were not visible on smile. The patient had a gummysmile. The patient had an unaesthetic smile arc and was very dissatisfied with her smile.

Pre treatmentextraoral photographs:
Intra-oral examination: Intraoral examination on frontal view showed presence of a complete deepbite of 7mm. On lateral view the patient showed the presence of Class II div 2 incisor relationship, an End OnClass II Canine relationship on both sides and an End On Class II molar relationship Bilaterally. Patient had an overjet of 0 mm and an overbite of 7 mm. There was crowding in upper and lower anterior region with irregularly aligned teeth.The upper and lower arch shows the presence of a "V" shaped arch form and the upper incisors were retroclinedindicative of a Class II division 2 malocclusion. The patient showed the presence of retained deciduous 2 nd molar in the lower right quadrant and also there was congenitally missing lower right 2 nd premolar.

Discussion:-
Before the Orthodontist can determine the optimal treatment, he or she must consider the contributing factors. These include normal growth and development, tooth size discrepancies; excessive incisor vertical overlap of different causes, mesiodistal and labiolingual incisor angulation, generalized spacing and pathological conditions.A carefully developed differential diagnosis allows the practitioner to choose the most effective orthodontic and/or restorative treatment. Treatment of Class II Div 2 malocclusion and gummy smilewithout extractions of premolars is challenging. A well chosen individualized treatment plan, undertaken with sound biomechanical principles and appropriate control of orthodontic mechanics to execute the plan is the surest way to achieve predictable results with minimal side effects.ClassII Division 2 malocclusion with crowding might have any number of a combination of the skeletal and dental components. Hence, identifying and understanding the etiology and expression of Class II Division 2 crowded malocclusion with a gummy smile and identifying differential diagnosis is helpful for its correction. The patient's chief complaint was irregular and crowded upper and lower front teeth and also excessive show of gums on smiing.The selection of orthodontic fixed appliances is dependent upon several factors which can be categorized into patient factors, such as age and compliance, and clinical factors, such as preference/familiarity and laboratory facilities.The execution of only Fixed appliance therapy appropriately resulted in an improvement in the patient's profile in this case. Alongside fixed orthodontic treatment, the retained deciduous tooth was removed and retraction was done in the area where the premolar was congenitally missing. The U1 to NA values both in degrees and in millimeters increased significantly thus changing the Class II division 2 incisor relationship to a Class I relationship.Successful results were obtained after the fixed MBT appliance therapy within a stipulated period of time.The overall treatment time was 15 months. After this active treatment phase, the profile of this 17 year old female patient improved significantly as seen in the post treatment Extra-oral photographs. Removable Hawleys retainers were then delivered to the patient.The crowding was corrected and the smile arc of the patient improved drastically to being consonant and pleasant. The patient was very happy and satisfied with the results at the end of the treatment.

Conclusion:-
This case report shows how the correction of gummy smile can be managed alongside fixed orthodontic treatment without the need for extractions, thus lowering the treatment time and enhancing the profile of the patient.The planned goals set in the pretreatment plan were successfully attained. Good intercuspation of the teeth was obtained and the unaesthetic appearing Clas II division 2 incisor relationshipwas changed to Class I relationship. Treatment of this case included the protraction of maxillary incisors with a resultant facial profile improvement. The maxillary and mandibular teeth were found to be esthetically satisfactory in the line of occlusion with a pleasing and consonant smile arc. Near idealoverjet and normal overbite was achieved at the end of treatment. The correction of malocclusion was achieved, with a significant improvement in the patient aesthetics and self-esteem. The patient was very satisfied with the results of the treatment.