"Global" Analysis Diagnosis

and Sequenced Treatment

coredentistry.com

Jeff Rouse, DDS

Lecture@RouseDDS.com

210.828.3334

1) Measure ― Glabella to Base of Nose

(Glabella is Synonymous with Mid-Brow Point)

― Base of Nose to Bottom of Chin in Repose

― Evaluate Symmetry

Face Height

Physiologic rest position assumed when the head is upright and involved muscles are in equilib-

rium in tonic contraction (Glossary of Prosthodontic Terms ― Academy of Prosthodontics 8th Edition. J.

Prosthet Dent. 2005; 91:10-92)

Definition ― Repose

Glabella- Mid-Brow Point

Evaluate Facial Transverse Symmetry Focusing on Chin Alignment

Patient in Repose

2) Rule

― Rule of Thirds- glabella to base of nose equal to base of

nose to bottom of chin

(Proffitt, LUM. Contemporary Orthodontics. 1992:150)

Lip Length

Lip Length

1) Measure

― In Repose

― Base of nose to inferior border of lip

― Chin point off of midline usually associated with

occlusal plane cant

― Proportion of lower third ― measured from lip

commissures. Maxilla comprises 1/3 and mandible 2/3.

2) Rule

― Average lip length 30 y.o.

― Female 20-22 mm

― Male 22-24 mm

(Vig, R, Brundo G. J Prosthet Dent 1978;39:503-504)

― Male lip length 2.2 mm longer than female

(Peck, S. etal J. Orhtodont. 1992; 101:519-524)

― Starting at age 40, the lip lengthens by 1 mm per decade

(Behrens, R. Monograph #17; Univ. of Michigan; 1985; 112-154)

Lip Mobility

1) Measure

― Distance lip travels from repose to full smile

― (Incisal edge to lip in full smile) - (incisal edge to lip in repose) = lip mobility

2) Rule

― Average lip mobility 6-8 mm

― Female smile 1.5 mm higher than male ― High smile ― female;

Low smile ― male (Peck, S. etal J. Orhtodont. 1992; 101:519-524)

15 mm lip length

30 mm lip length

1) Measure

― Midline centrals = Midface

Dental Facial Midline

― Cant to midline

2) Rule

― ≤ 2mm midline deviation acceptable

― Cant unacceptable

(Kokich, VO. Jr., Kiyak HA, Shapiro PA. J Esthet Dent. 1999; 11:311-324)

4 mm midline deviation

1) Measure ― Incisal Display In Repose― +/-

Centrals In Repose

― Negative Measure Is Aged Look

1) Measure ― Tooth Gingival Interface to Lip

― +/-

― Relaxed and ‘E’ Smile

2) Rule ― Ideal Smile Lip translates to Tooth

Gingival Interface

(T Jan AH, et. al. J Prosthet Dent. 1984; 51: 24-28)

― Gummy Smile ― +2 mm of marginal gingival display

― “Aged smile” ― -2mm of tooth display

Gingival Line to Upper Lip in Full Smile

Gummy Smile Aged Smile

2) Rule ― Female 30 y.o. 3-4 mm Exposed― Male 30 y.o. 1-2 mm Exposed

(Vig, R, Brundo G. J Prosthet Dent 1978;39:503-504)

1) Measure ―Length & Width #5-12

2) Rule ― Max Central ― 10.2 mm, Max. Lateral ― 8.2 mm, Max. Canine ― 10.4 mm (Kois, J, Unpublished Data 1989)

― Ratio Height to Width 1.2:1― Mean length for central incisal greater for males than female (Peck, S. et. et. J Orthodont. 1992; 101:512-524)

― Change Height to width ratio― Surgical crown lengthening― Lengthening of incisal edges― Redistributive space othodontically― Soft tissue graft

Length of Maxillary Anteriors

1) Measure ― Gingival Line from Canine to Canine

― Note Gingival Relationship

― Relaxed and ‘E’ Smile

2) Rule ― Horizontal Symmetry with Canines and Centrals on Line,

Laterals on or Below Line up to 1 mm

― Perfecting gingival architecture key to rehabilitation

Tissue Levels

1)) Measu ― Only on short teeth― Sharp explorer, feel for “Pebbly”

roughness of CEJ

) Ru2) ― Short teeth without CEJ located diagnostic for Altered Passive Eruption

CEJ Located

Feel CEJ Cannot Detect CEJ

Upper Lip Dimensions

― 20-22 mm female, 22-24 male― Lengthens 1 mm per decade after 40 y.o.

Treatment― Patient education

Lip Problems ― “Global” Diagnosis

― Lip problem― Short clinical crowns ― Vertical problems ― Combination

Rule― Rule of thirds descriptive

― Cephalometric Analysis Diagnostic

Vertical Maxillary Excess

Treatment― Othognathic surgery

― “Change life”

― Botox

“Global” Classification

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Lip Activity― Rule

― Average lip mobility 6-8 mm― Lip may be hyper or hypomobile

Treatment― Patient education― Botox― Plastic surgery?― Hypertrophy of depression septic nasi muscle,

reaches nasal tip, drooping of tip in smile (Cachay-Velasquez, H. Ann Plast Surg. 1992; 28:427-433)

Hyperactive

Hyperactive

Rule― Gingival line horizontal symmetry― Opposed eruption ― tooth wear, compensatory eruption― Unopposed eruption ― CL II occlusion, missing teeth― Concave gingival architecture

Dentoalveolar Extrusion

Supraeruption― 33% opposed posteriors, mean amount 0.24 mm

― 92% unopposed posteriors, 68% > 1 mm, 27% mm mean 1.68 mm, greater in maxilla

(Craddock, H. et. al. J Prosthodont 2007; 16:485-494)

Periodontal Growth― Gain attachment― Maxillary more common, younger patients

Patterns of Eruption― Active eruption

― Associated with attachment loss

Relative Wear― Increases with age― Mandibular

Patterns of DAE

DAE with WEAR DAE withou WEAR

Treatment― Functional crown lengthening― Segmental osteotomy― Orthodontic intrusion― Increase vertical dimension

― Only if incisal edge position allows

Othodontic Intrusion1) 6-12 Months Duration2) Relapse High, Retention Critical3) Relative vs. Absolute

Relative Intrusion1) Partial Extrusion, Partial Intrusion2) Mechanics Less Focused on Side Effects3) Case Selection – Decreased Lower Face

Height, Decreased Mandibular Plane Angle,Growing Patients

Absolute Intrusion1) No or Very Limited Extrusion2) Maximize Anchorage – Teeth (Segmentally,

Intrusion Arches), Adjunctive (Implants,Temporary Anchorage Device)

3) Case Selection – Increased Lower Face Height,Increased Mandibular Plane Angle, CantedOcclusal Plane, Dentoalveolar Extrusion

3) Gingival Line Rule

― Ideal horizontal symmetry ― canine-central-central-canine

― Concave gingival architecture with or without wear

The Five Questions ??? (cont’d)

― Can be anywhere in mouth

Diagnosis: Dentoalveolar Extrusion

Treatment: ― Functional crown lengthening

― Segmental osteotomy

― Orthodontic intrusion

― Increase vertical dimension

4) Tooth Length? Rule ― 10:2 mm central, 8.9 mm lateral, 10.5 mm canine ― 1.2:1.0 height to width ratio Diagnosis ― Anatomic variation ― ratio must be correct ― Incisal wear ― Dentoalveolar Extrusion ― Altered Passive Eruption ― need CEJ information

Treatment ― Anatomic variation ― align gingiva, correct spacing and restore ― Incisal wear ― Treat Dentoalveolar Extrusion ― Altered Passive Eruption ― cannot diagnose without CEJ information

1) Anatomic Variation

Rule ― 1.2:1.0 height width ration― Rare― Peg and small laterals most common

Treatment― Orthodontics and restorative dentistry

Short Clinical Crowns

2) Incisal Wear

Rule ― Teeth should not physiologically wear past the enamel― Generalized or localized― Associated with extrusion

Treatment― Restorative, periodontal, orthodontic

3) Altered Passive Eruption

Rule ― Short teeth, cannot locate CEJ― 10-15%, females > males― Unknown etiology

Eruptive Process

― Active eruption ― occlusal movement of tooth as it emerges from gingiva, stops with contact

― Passive Eruption ― Apical shift of dentogingival complex

Altered Passive Eruption

― Gingival margin and osseous malpositioned incisally on anatomical crown (Coslet J, et. al. Alpha Omegan. 3:1977)

Treatment

― Gingivectomy― Osseous Surgery― Age: +15 y.o. no apical change

Anatomical Considerations

― Osseous architecture― Horizontal Symmetry― 2 mm apical to CEJ― Dictates gingival level

― Dentogingival Complex ― Varies from tooth-to-tooth ― Connective tissue

― Strong fibrous attachment to root ― Nerve and blood supply― Epithelial attachment

― Hemidesmsomal wear attachment― Cells turn over 4-6 days

― Sulcus ― Cannot determine clinically― Not equal to probing depth

Active Eruption

Passive Eruption

Altered Passive Eruption

Bone Sounding

― Measure total dentogingival complex― Technique

1) Local anesthetic2) Probe sulcus - feel resistance3) Angle probe on root surface4) Force to osseous crest

85% Normal CrestTreatment ― tissue levels stable, finish line minimal 2.5 mm from osseous, retraction technique no critical

Facial: 3 mm

Interproximal: > 4.5 mm

Facial: < 3 mm

Facial: > 3 mm

Interproximal: < 3 mm

Interproximal: 3-4.5 mm

13% Low Crest― Tissue levels unstable, high risk for facial recession or black triangles― Limit gingival trauma, retraction cord

minimal & limit time

2% High Crest ― Risk for biologic width violation― Surgically resolve?― Finish line less than 0.5 mm

apical to FGM

Facial Interproximal

1) Face Height? ― Rule of thirds ― mid face and lower face measurements

The Five Questions ???

Diagnosis ― Excess maxilla = Vertical Maxillary Excess Treatment ― orthognathic surgery

2) Lip Length/Mobility? ― 20-22 mm female, 22-24 mm male, 30 y.o. ― Lengthens 1 mm per decade after 40 y.o. Diagnosis: Upper lip dimensions ― short or long lip Treatment: Patient education ― Average mobility 6-8 mm

Diagnosis: Lip mobility ― Hypo or hypermobile lip Treatment: Hypermobile ― Patient education ― Botox ― Plastic surgery?

Short Lip

HyperHypo

Treatment: Hypomobile ― Patient education ― Botox

5) CEJ? Rule

― Sharp explorer under FGM to detect roughness of CEJ

The Five Questions ??? (cont’d)

Diagnosis: Short Tooth

― Detect CEJ ― tooth is anatomic variation or DAE with wear

― Short tooth do not detect CEJ ― Altered Passive Eruption

Treatment APE: Osseous Surgery