Lasers and Orthodontics

Resolution of a ‘Gummy Smile’Using the the DNA® Appliance®

Lasers and Orthodontics

Resolution of a ‘Gummy Smile’Using the the DNA® Appliance

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Using The DNA® ApplianceUsing The DNA® Appliance

Traditionally, orthodontistshave used fixed appliancesto apply forces to moveteeth. The disadvantage of

this approach is that inflammatorypathways are activated1, whichinduce discomfort throughout thetreatment. Furthermore, the tacitassumption is that when the teethare leveled, aligned and rotated, thepatient will be in a better state oforal health. However, there areother co-morbid conditions associ-ated with malocclusions, such astemporo-mandibular joint (TMJ)dysfunction/headaches,snoring/obstructive sleep apnea

(OSA) etc. that are often inadver-tently overlooked or ignored. There-fore, it might be better to take amore holistic approach and providea more thorough craniofacialcorrection rather than attempt totreat the teeth in isolation. Indeed,while many cases are initiallytreated successfully, orthodontistsknow that relapse can occur aftertreatment. The reasons for relapseare complex and remain incom-pletely understood.

Non-extraction protocols appealto many clinicians practicingmodern-day orthodontic correctionas a way to reconcile dental andskeletal tissue relationships. In this

regard, the DNA appliance system isdesigned to correct maxillo-mandibular underdevelopment inboth children2 and adults.3-4 Theacrylic-based DNA appliance (Fig. 1)typically has: 6 (patented) anterior 3-D axial springsTM, a midline screw,posterior occlusal coverage, retentiveclasps, and a labial bow. The DNAappliance is preferentially worn forapprox. 12-16 hrs. during the after-noon, evening and at nighttime, butnot during the day and not whileeating, partly in line with the circa-dian rhythm of tooth eruption.5 Theaim of this study is to report theeffects of oral myofunctional therapy(OMT), craniofacial development

By G. Dave Singh, DDSc, PhD, BDS and William G. Harris, BSc, DDS

www.orthodontics.com July/August 2013 31

with the DNA appliance, and casefinishing with a fixed orthodonticappliance in an adult female whowas previously orthodontically-treated as a teenager.

CASE HISTORYA 39 year old woman presented

to a dental office (All North Dental)requesting orthodontic treatment.The chief complaint was a ‘gummysmile’. The medical history revealedno relevant conditions or medica-tions. The patient indicated that shewas a mouth-breather, and that shehad her tonsils removed at age 4yrs. In response to a sleep screeningquestionnaire, she responded that:it took her approx. 30 mins. to fallasleep; had a history of waking upgagging/choking and coughing, andthat she did not wake up feelingrefreshed. She indicated that shehad been tested for OSA but the testresult was negative. She also volun-teered that she clenched her teethduring the day, and was inclined togrind her teeth at night. Her dentalhistory revealed that she hadorthodontic treatment from age 13-16yrs. and that she did notpresently have a retainer. Extra-oralexamination revealed evidence offacial asymmetry with unilateralnarrow nares, a thin upper lip andanterior open bite. Vertical maxil-lary excess (‘gummy smile’) wasnoted on full smile (Fig. 2).

Intra-oral examination revealedan anterior open bite (AOB) withanterior tongue thrust on swallow-

ing (Fig. 3). There was excessivewear of the cuspids and posteriorteeth, and crowding of the upperand lower arches. Panoramic radiog-raphy revealed horizontalimpaction of the lower thirdmolars, with the upper third molarshaving been previously extracted.Tomographic radiographs of theTMJs showed some evidence ofdegeneration of the left condyle. Aworking diagnosis of Class I maloc-clusion with apertognathia compli-cated by protrusive bruxism wasreached; with a differential diagno-sis of upper airway resistancesyndrome. After obtaining informedconsent, it was agreed that thepatient would be treated with OMT,a maxillary DNA appliance, and amandibular DNA appliance or fixedorthodontics as needed, followed byappropriate retention.

PROTOCOLAlginate impressions were taken

and the bite registration wasrecorded, using a phonetic biteregistration.6 An acrylic-based DNAappliance was fabricated (SpaceMaintainers Laboratory, Canada)and fitted. The patient wasinstructed to wear the appliancefor 12-16 hrs. during the late after-noon, evening and at nighttime,but not during the day nor whileeating. The patient was advised touse retainer-cleaner tablets but nota toothbrush to keep the applianceclean. Adjustments were madeperiodically every 4-6 weeks tokeep the appliance in balance forthe patient. Craniofacial develop-ment continued for 9 months intotal, during which time the DNAappliance was replaced with fixedorthodontics to accomplish the

Fig. 1

Fig. 2

Fig. 3

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occlusion goals, which includedanterior coupling. In this case,Speed brackets (Speed SystemOrthodontics, Cambridge, ON,Canada) were used in the follow-ing wire sequence: 0.014, 0.016,0.018 with vertical elastics. Theduration of fixed appliance ther-apy was 8 months in total.

The patient was also instructed inOMT to train the tongue, followinga routine prescribed by a trainedoral myofunctional therapist. Thisroutine consisted of a series of exer-cises to retrain the tongue to rest inthe roof of the mouth. It alsoencouraged a lips-together posture,and promoted breathing throughthe nose while at rest.

RESULTSThe patient reported that the

DNA appliance was comfortableand there was no pain while wear-ing it. Arch development andbony remodeling of the palatenecessitated periodic acrylicadjustments. After 7 weeks withone maxillary, acrylic-based DNAappliance, a significant improve-ment in lip posture/morphologyand vertical maxillary excess wasnoted (Fig. 4). After 9 months ofDNA appliance therapy and 8months of fixed orthodontics, thepatient was very pleased with theclinical results (Fig. 5), whichincluded a wider smile, no‘gummy smile’, anterior teeth ableto couple for the first time (Fig.6), and she reported no incidentsof gagging, choking or coughingduring sleep.

DISCUSSIONThe human genome has been

sequenced, and we now know thatcertain genes are involved inremodeling bone1, tooth develop-ment7 and tooth eruption.8 Teethare naturally-designed to move; forexample, tooth eruption in anormally-growing child. In addi-tion, the teeth in some people eruptin a specific arrangement, produc-ing a beautiful smile. The uniquearrangement of teeth is due tohomeobox genes9 that help producean ideal bone morphology. In fact,a natural process called 'temporo-spatial patterning' is at work.10 Thisprocess can be regarded as ablueprint or body plan that isencoded by genes. In fact, the axesof the entire body are under geneticregulation; a phenomenon calledpattern formation11 under the influ-ence of an organizer region of thebody plan, including the teeth.Commonly, however, the body planundergoes environmental perturba-

tions, producing malocclusions.12

The DNA appliance system puta-tively uses a biomimetic approachto address these issues, invoking theconcept of epigenetic orthodonticsor gene-environmental interactions.

Anterior open bite can bedivided into two etiologic cate-gories: skeletal and dento-alveolar.Thus, therapeutic success relies onboth structural and functional reha-bilitation to guarantee stability oftreatment.13 Indeed, conventionaltreatment modalities for an AOBusually include orthodontic treat-ment combined with orthognathicsurgery, but other restorativeoptions for treatment can besuccessful.14 However, alternativemethods that harness physiologicprocesses might also be advanta-geous. For example, Chate andFalconer15 used a simple orthodon-tic method to achieve re-intrusionof over-erupted teeth that wereassociated with AOB. More typi-cally, a combined orthodontic-orthognathic protocol is used tocorrect AOB. However, Jensen andRuf16 evaluated the short-termsuccess of combined orthodontic-surgical correction of AOB. Theyconcluded that normal overjet andoverbite with proper incisal contactis achieved in only 40% of subjectsusing that approach. Yet anotherapproach in the correction of AOBis the use of temporary anchoragedevices (TADs). For example, Wald-man17 used orthodontic TADs toprovide a novel alternative toorthognathic surgery. The TADsprovided skeletal anchorage formaxillary molar intrusion, allowingmandibular autorotation and subse-quent open-bite closure. However,orthodontic mechanics were stillneeded at every stage in that case,unlike the case that we report here.Another difference in the protocolthat we adopt here is the integra-tion of an oral myofunctional ther-apist. Smithpeter and Covell18

reported that OMT in conjunctionwith orthodontic treatment ishighly effective in maintainingclosure of AOB compared withorthodontic treatment alone. There-fore, we anticipate a stable result inthis case; however, long-term review

“This particular casewas treated witha DNA appliancebecause diagnostic

clinical facial featureshighlighted a need

for midfacialdevelopment.”

Fig. 4 Fig. 5

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will continue to ensure that relapsedoes not follow this initially-successful outcome. Indeed, thepatient continues to wear the upperDNA appliance passively at night-time only; not as a retainer per sebut as an ‘anti-aging device’ toprevent vertical drift of the facethat occurs with age.

In summary, advances in technol-ogy and molecular science providenew approaches to orthodontic carein the 21st century for both adultsand children. Molecular biology andmolecular genetics have allowedhuman craniofacial growth anddevelopment to be studied andunderstood in ways that were notavailable previously. Thus, informa-tion on how natural developmentalprocesses can be harnessed for clini-cal orthodontic correction is begin-ning to emerge. By understandingand appreciating developmentalmechanisms and the sites andmodes of tissue interactions, thenatural processes of jaw growth andtooth movement can be mimickedfor the benefit of the orthodontic

patient. This particular case wastreated with a DNA appliancebecause diagnostic clinical facialfeatures highlighted a need formidfacial development. However,rather than conventional mechanics,the utilization of craniofacial growthand developmental processes wasenvisaged, using orthodontic wirefor signal transduction.19 Indeed,discernible changes were noted inthe face, jaws and teeth. We believethese changes equate to an increasedlevel of craniofacial homeostasis, inaccord with the Spatial MatrixHypothesis.20-21 These early results

abide by principles under the novelconcept of biomimetic orthodonticcorrection, which takes craniofacialgrowth and epigenetics into accountfor orthodontic corrections associ-ated with an enhanced level of cran-iofacial homeostasis.

ACKNOWLEDGEMENT: Wewould like to thank oral myofunc-tional therapist Natalie Mack,RDA, for providing oral myofunc-tional therapy in this case. Wewould also like to thank SpaceMaintainers Laboratory, Canada)for fabricating the DNA applianceprescribed in this case.

Fig. 6

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REFERENCES1. Roberts, W.E., Epker, B.N., Burr, D.B.,

Hartsfield, J.K., Roberts, J.A.: Remodelingof mineralized tissues, Part II: Controland Pathophysiology. Seminars Orthod12:238-253, 2006.

2. Singh, G.D., Lipka, G.: Case Report:Introducing the wireframe DNA appli-anceTM. J Am Acad Gnathol Orthop26;8-11, 2009.

3. Singh, G.D., Wendling, S., Chan-drashekhar, R.: Midfacial development inadult obstructive sleep apnea. Dent Today30;124-127, 2011.

4. Singh, G.D., Utama, J.: Effect of the DNAapplianceTM on migraine headache: Casereport. Int J Orthod 24: 45-49, 2013.

5. Proffit, W.R., Frazier-Bowers, S.A.: Mecha-nism and control of tooth eruption:overview and clinical implications.Orthod Craniofac Res 12:59-66, 2009.

6. Singh, G.D., Olmos, S.: Use of a sibilantphoneme registration protocol to preventupper airway collapse in patients withTMD. Sleep Breath 11:209-216, 2007.

7. Frazier-Bowers, S.A., Guo, D.C., Cavender,A., Xue, L., Evans, B., King, T., Milewicz,D., D'Souza, R.N.: A novel mutation inhuman PAX9 causes molar oligodontia. JDent Res 81:129-133, 2002.

8. Philbrick, W.M., Dreyer, B.E., Nakch-bandi, I.A., Karaplis, A.C.: Parathyroidhormone-related protein is required fortooth eruption. Proc Natl Acad Sci95:11846-11851, 1998.

9. Weiss, K.M., Bollekens, J., Ruddle, F.H.,Takashita, K.: Distal-less and other home-obox genes in the development of thedentition. J Exp Zool 270:273-284, 1994.

10. Chaplain, M.A.J., Singh, G.D., McLach-lan, J.C.: On growth and form: Spatio-temporal patterning in biology. JohnWiley &Sons, England; 1999.

11. Wolper, L.: Pattern formation in biologi-cal development. Sci Amer 239: 154–164,1978.

12. Corruccini, R.S., Townsend, G.C.,Richards, L.C., Brown, T.: Genetic andenvironmental determinants of dentalocclusal variation in twins of differentnationalities. Hum Biol 62:353-267, 1990.

13. Halimi, A., Zaoui, F.: Open bite and ther-apeutic strategy. Odontostomatol Trop33:35-48, 2010.

14. Parlani, S., Patel, S.: Esthetic correction inopen bite. Indian J Dent Res 22:580-582,2011.

15. Chate, R.A., Falconer, D.T.: Dental appli-ances with inadequate occlusal coverage:a case report. Br Dent J 210:109-110,2011.

16. Jensen, U., Ruf, S.: Success rate of ante-rior open-bite orthodontic-orthognathicsurgical treatment. Am J Orthod Dentofa-cial Orthop 138:716-719, 2010.

17. Waldman, A.B. Orthodontic treatment ofa complex open-bite malocclusion withtemporary anchorage devices: a casereport. J Calif Dent Assoc 38:591-600,2010.

18. Smithpeter, J., Covell, D. Jr.: Relapse ofanterior open bites treated withorthodontic appliances with and withoutorofacial myofunctional therapy. Am JOrthod Dentofacial Orthop 137:605-614,2010.

19. Sandy, J.R.: Signal transduction. Br JOrthod 25:269-274, 1998.

20. Singh, G.D., Krumholtz, J.A.: Epigeneticorthodontics in adults. Chatsworth:Appliance Therapy Group, Chatsworth,CA; 2009.

21. Singh, G.D.: In growth and treatmentThe spatial matrix hypothesis. In:Growth and treatment: A meeting of theminds. University of Michigan Craniofa-cial Growth Series, Ann Arbor; 2004.