Gummy Smile and 100% Deep Bite and Full Cusp Class II

Presentation

Chief complaint. " I would like a second opinion. One doctor says I need to take teeth out and the other surgery."

Diagnosis. She presents with a full-cusp Class II Division 2 malocclusion, a 5 mm overjet, and a 100% impinging deep overbite. She has a convex facial profile with an obtuse nasolabial angle and a retrognathic mandible, contributing to the underlying skeletal Class II relationship. The maxillary incisors are retroclined, while the mandibular incisors are well positioned. She demonstrates a hypodivergent skeletal pattern with decreased lower facial height, consistent with her severe deep-bite presentation. CVM CS3

Why I chose this approach

This patient sought a second opinion after receiving recommendations for extractions or surgery. My goal was to explore a conservative approach that would correct her impinging deep bite, improve her smile, and address the Class II relationship while using her remaining growth potential. Her upper incisors were tipped inward, and her deep bite was associated with decreased lower facial height. I chose braces to improve the inclination of the upper incisors, intrude them as part of the planned bite and smile correction, and level both arches. Her initial CVM assessment suggested CS3, so I incorporated Forsus into the plan to correct the Class II relationship through dental movement while allowing remaining mandibular growth to contribute. Before placing Forsus, I progressed to rigid stainless steel wires and cinched the lower archwire to reinforce anchorage and limit unwanted forward tipping of the lower incisors. She ultimately demonstrated less mandibular growth than anticipated, so more of the correction came from dental compensation. Despite the anchorage precautions, her lower incisors became more proclined during treatment. This was an important tradeoff in achieving the bite correction without extractions or surgery. We reduced both overjet and overbite to 2 mm and substantially improved her alignment and occlusion. The underlying skeletal Class II relationship remained, but the final result provided a more functional bite and a pleasing smile.

Cephalometric values before and after treatment
Measure	Norm	Pre	Post
SNA	82	84	83
SNB	80	75	76
ANB	2	9	7
Wits	0	5	1
SN-MP	32	25	27
U1-SN	102	89	100
L1-MP	90	98	105
Overjet (mm)	2–3	5	2
Overbite (mm)	2–3	5	2

Measure

Norm

Pre

Post

SNA

SNB

ANB

Wits

SN-MP

U1-SN

102

100

L1-MP

105

Overjet (mm)

2–3

Overbite (mm)

2–3

Treatment

Objectives. Level and align both arches, intrude the upper incisors. advance the lower jaw to maximize growth.

Plan. Band the maxillary first molars (U6s) and bond all remaining teeth 7–7. Use 022 MBT Unitek brackets. Procline the maxillary incisors to improve their inclination and help correct the Class II Division 2 incisor relationship. Progress through the archwire sequence until a .019 × .025 stainless steel wire is in place. Cinched back the mandibular archwire before Forsus placement to reinforce anchorage and minimize unwanted lower incisor proclination. Place Forsus appliances bilaterally to advance the mandibular dentition and correct the Class II relationship. Maintain the Forsus for approximately 6–8 months, or as needed to achieve adequate sagittal correction. Continue detailing and finishing to obtain an ideal Class I relationship, overjet, overbite, and arch coordination.

Appliances and materials

Braces — 022 MBT unitek

Forsus — Class II corrector

Outcome

We successfully leveled and aligned both arches and corrected the deep overbite and increased overjet, resulting in a significantly improved Class II relationship and overall occlusion. Although her initial CVM assessment suggested CS3 with remaining mandibular growth potential, she demonstrated less mandibular growth than anticipated during treatment, suggesting that she may have been further along in her growth trajectory than initially estimated. As part of the Class II correction, the mandibular incisors proclined and finished somewhat more proclined than their pretreatment position. Overall, we achieved a well-aligned dentition with substantially improved overjet, overbite, and occlusal relationships, resulting in a pleasing functional and esthetic outcome.

Retention

Fixed U2-2 permanent retainer

Fixed U3-3 permanent retainer

Invisalign Vivera retainers to be worn at night