Bimaxillary protrusion and gummy smile treated with clear aligners: Closing premolar extraction spaces with bone screw anchorage

Inadequate posterior anchorage is a serious limitation for aligner treatment involving extraction of four first premolars. Inappropriate axial inclinations may compromise intermaxillary occlusion and stability. OrthoBoneScrew® (OBS) anchorage is designed to augment the Invisalign® clear aligner G6 solution to produce more predictable outcomes as illustrated by the current case report. An 18-year-old female presented with two chief complains: (1) Protrusive, incompetent lips, and (2) excessive gingival exposure when smiling (“gummy smile”). Clinical evaluation revealed bimaxillary protrusion, hypermentalis activity, anterior crowding, and excessive anterior axial inclinations, particularly of the lower incisors (116°). The American Board of Orthodontic (ABO) discrepancy index (DI) was 21. The treatment plan was extraction of all four first premolars, and clear aligner (Invisalign®) therapy anchored with four OBSs: Infra-zygomatic crest (IZC), and between the roots of the upper central and lateral incisors (Incisal) bilaterally. Eighteen months of initial treatment with 45 aligners retracted and intruded the anterior segments in both arches by closing the extraction spaces with supplemental anchorage provided by IZC and Incisal OBSs. The final series of 20 refinement aligners achieved an excellent outcome as evidenced by an ABO cast-radiograph evaluation (CRE) score of 10, and a pink and white (P&W) dental esthetic score of 3. Post-treatment analysis revealed multiple opportunities for improvement. The patient was well satisfied with the final outcome.