Psychological Impact of Excessive Anterior Tooth Display and Its Correction Using a Utility Arch: A Case Report

INTRODUCTION

The aesthetic appearance of the smile plays a crucial role in an individual’s self-esteem and social interactions, especially during adolescence formative period for psychological and emotional development. Excessive anterior tooth display, often perceived as an aesthetic concern, can significantly impact an adolescent’s body image and psychological well-being.^[1,2]

Malocclusion and abnormal tooth display have been associated with decreased self-confidence and increased social anxiety, affecting overall quality of life.^[1,3]

Orthodontic interventions in case of excessive upper incisors not only improve dental function but also contribute positively to patients’ psychological well-being.^[2,4]Among various treatment modalities, the use of a utility arch for maxillary incisor intrusion has shown effective clinical outcomes with minimal adverse effects.^[5,6] This technique facilitates controlled intrusion of the anterior teeth, thereby reducing excessive tooth display and enhancing lip competence without increasing lower facial height.^[7] Despite its clinical benefits, careful diagnosis and monitoring are essential to avoid potential complications such as root resorption.^[8]

This case report aims to illustrate the psychological impact of excessive anterior tooth display in an adolescent patient and to present the clinical management using a utility arch, highlighting both the functional and psychosocial benefits of this treatment approach.

Clinical examination

Extraoral facial assessment revealed no evidence of facial asymmetry. The lower third of the face was slightly increased in proportion, contributing to an overall vertical facial excess [Figure 1]. The patient presented with a convex facial profile, a deep sulcus, and a lip trap. Lip incompetence was evident, with an excessive display of the maxillary anterior teeth both at rest and during smiling, which contributed not only to esthetic concerns but also to the patient’s reported self-consciousness during social interactions. After the psychosocial impact of dental aesthetics Questionnaire (PIDAQ),^[9] the total score for the patient was 49, indicating that the patient exhibited an initial lack of confidence, leading to psychological distress and poor social interaction.

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Figure 1: Pretreatment extraoral photograph (a) Front view, (b) front smile view, (c) profile view. Pretreatment intraoral photographs, (d) maxillary arch, (e) mandibular arch, (f) right view, (g) front view, (h) left view. Pretreatment radiographs, (i) lateral cephalogram, (j) orthopantomogram.

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Smile analysis revealed approximately 100% incisal display associated with the presence of lateral negative space (buccal corridors). Intraoral assessment indicated that the patient was in late mixed dentition with satisfactory oral hygiene, bilateral Angle’s Class I molar relationship, Class II incisor relationship, erupting upper and lower canines, and second premolars, along with retained upper right and lower left deciduous second molars [Figure 1].

The maxillary incisors were proclaimed and excessively over-erupted, resulting in increased overjet and deep overbite. A midline diastema with a 2 mm rightward shift was present. Mild crowding is present in the lower arch. Cephalometric analysis revealed a skeletal Class II pattern due to a retrusive mandible and a vertical growth tendency. The maxillary incisors were proclaimed, while the mandibular incisors were retro lined [Figure 1] [Table 1].

Table 1: Cephalometric analysis showing pre-treatment, post-intrusion, and post-treatment values

Parameters	Normal values	Pre treatment	Post intrusion	Post treatment
Skeletal relationship
SNA	82° ± 2°	82°	83°	84°
SNB	80° ± 2°	77°	79°	80°
ANB	2° ± 2°	5°	4°	4°
Wits appraisal	0 mm	5 mm	5 mm	5 mm
Dental base relationship
Upper incisor to NA (mm/degree)	4 mm / 22°	10 mm / 35°	7 mm / 33°	9 mm / 30°
Lower incisor to NB (mm/degree)	4 mm / 25°	6 mm / 20°	7 mm / 25°	11 mm / 33°
Upper incisor to SN plane	102° ± 2°	117°	117°	114°
Lower IMPA	90°	86°	91°	97°
Dental relationship
Interincisal angle	131°	120°	117°	114°
Lower incisor to Apo line	0 – 2 mm	4 mm	3 mm	8 mm
Overbite	2 mm	8 mm	5 mm	4 mm
Overjet	2 mm	12 mm	7 mm	4 mm
Maxillary incisal edge to palatal plane	28 mm	29mm	26mm	29mm
Vertical skeletal relationship
Maxillary–Mandibular plane angle	25°	32°	29°	30°
SN plane – mind plane	32°	40°	37°	34°
Upper anterior face height	50 ± 2.4 mm	50	50	53
Lower anterior face height	67.2 (4.7) mm	61	62	65
Face height ratio (%)	45:55	45:55	44:56	43:58
Jerabek ratio	62–65%	61	64	64
Soft Tissue
Lower lip to ricketts E plane	-2 mm	+3 mm	+3 mm	+1 mm
Nasolabial angle	90°–110°	66°	73°	84°

SNA: Sella–nasion–A point angle, SNB: Sella–nasion–B point angle, ANB: A point–nasion–B point angle, NA: Nasion–A point, NB: Nasion–B point, SN: Sella–nasion plane, IMPA: Incisor mandibular plane angle.

Panoramic radiograph (OPG) showed unerupted teeth 15, 25, and 35, with retained 55, 65, and 85, and the eruption of all second permanent molars. Open root apices were observed in most developing teeth [Figure 1].

Treatment progress

A non-extraction approach was used, starting with a maxillary utility arch (17×25 Titanium Molybdenum Alloy (TMA) wire) for incisor intrusion, which lasted for 8 months, followed by fixed mechanotherapy. Alignment was achieved using progressively larger Nickel Titanium (NiTi) wires (0.014-in to 0.017×25 NiTi) and finishing on 0.019×0.025-in archwires. Fixed retainers were bonded in both arches [Figures 2 and 3].

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Figure 2: Intrusion utility arch, with (a) frontal smile, (b) right and (c) left view.

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Figure 3: Post intrusion extraoral photograph (a) Front view, (b) front smile view, (c) profile view. Post intrusion intraoral photographs, (d) maxillary arch, (e) mandibular arch, (f) right view, (g) front view, (h) left view. Post intrusion radiographs, (i) lateral cephalogram, (j) orthopantomogram.

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RESULTS

Treatment resulted in Angle’s Class I molar and canine relations, with 2 mm overjet and overbite, and a harmonious soft tissue profile. The patient reported significant improvements in self-esteem and social confidence. Post-treatment radiographs showed well-aligned roots. Cephalometric superimposition revealed 2 mm upward and backward movement of maxillary incisors, 5 mm forward movement of mandibular incisors, and a 6° reduction in SN-MP angle. Reduction in SN-MP angle attributed to treatment mechanics, i.e., intrusion of maxillary teeth and resumption of favourable growth pattern, resulted in counter-clockwise autorotation of the mandible contributing to enhanced facial esthetics [Figures 4 and 5].^[10]

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Figure 4: Posttreatment extraoral photograph (a) Front view, (b) front smile view, (c) profile view. Post treatment intraoral photographs (d) maxillary arch, (e) mandibular arch, (f) right view, (g) front view, (h) left view. Post treatment radiographs, (i) lateral cephalogram, (j) orthopantomogram.

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Figure 5: Superimposition

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DISCUSSION

Excessive anterior tooth display, especially when smiling, can significantly affect adolescents' psychosocial s-being. Studies show that 98% experience some psychosocial impact from dental esthetics, with prominent tooth or gum display linked to lower self-esteem and reduced oral health–related quality of life (OHRQoL).^[11]

In adolescents, maxillary incisor visibility greatly influences self-perceived dental esthetics. High smile lines and visible teeth can lead to negative self-image, even with mild malocclusion. Additionally, self-esteem and body image are key factors in orthodontic treatment's impact on psychosocial well-being.^[6]

Importantly, orthodontic treatment can significantly improve adolescent patients’ psychosocial domains. A large prospective study found consistent improvements in self-esteem, body image, and social functioning after treatment, independent of initial clinical severity.^[6] Adolescents who received orthodontic correction reported enhanced satisfaction with their dental appearance and lower negative emotions affecting self-confidence.^[4]

Utility arch mechanics, like the Ricketts intrusion arch, offer an effective non-surgical option for managing excessive anterior display in deep bite and gingival smile cases. Clinical studies show that utility arches achieve about 1.4 mm of incisor intrusion, compared to 2.1 mm with mini-implants, which have additional considerations; though slightly less intrusive, utility arches still reduce incisal exposure and enhance lip competence.^[7]

Clinical literature emphasizes the importance of early interception of visible malocclusion traits such as increased overjet, spacing, or protrusion. These characteristics have been strongly linked to lower self-esteem and increased risk of teasing or stereotyping in adolescents.^[12] Correcting these traits early can prevent the compounding psychological impact that persists into later life. Similar findings were observed when the Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) was administered post-treatment, with scores increasing to 15, indicating improved psychosocial outcomes.

In the present case, excessive anterior tooth display associated with his initial lack of confidence led to psychological distress and interacting socially. The successful reduction of incisal display using the utility arch not only improved facial balance and smile aesthetics but also enhanced the patient's self-esteem and overall satisfaction with his appearance. This outcome aligns with literature suggesting that esthetic orthodontic correction contributes to emotional well-being, especially during adolescence.^{[2, 4, 6]}

CONCLUSION

Excessive anterior tooth display, even with mild malocclusion, can significantly impact an adolescent’s self-esteem and social confidence. This case demonstrates how a maxillary utility arch offers a non-extraction, minimally invasive solution that improves both esthetics and function, while also delivering notable psychosocial benefits. This case showed the importance of incorporating psychological and emotional considerations into orthodontic treatment planning, especially in young patients, to ensure comprehensive and lasting outcomes.