Orthodontic Treatment Planning:

From Problem List to Specific Plan

Chapter 07
 Content
• Skeletal problems:Macroesthetic consideration
– Orthodontic camouflage
– Surgery
– Growth modification
• Mini esthetic consideration:
– Vertical tooth lip relationship
– Transverse dimension of smile
– Smile arc
– Smile symmetry
Skeletal Problems: Macro-Esthetic
Considerations
• In planning treatment for skeletal problems :
• orthodontic treatment
– either by compensatory tooth movement and
frequently extraction (camouflage)
– or growth modification, can bring the patient
close enough to normal for esthetic social
acceptability,
• Or a combination of orthodontics and surgery
would be required .
There are three possibilities:
(1) orthodontic camouflage,
(2) orthognathic and/or plastic surgery,
(3) for growing patients only, orthodontic
growth modification.
 Orthodontic Camouflage

• If you can make facial disproportion disappear

without changing the jaw proportions that
underlie it, you have solved the patient’s
problem satisfactorily by camouflaging it.
• Orthodontic camouflage of mandibular
deficiency by retracting the upper incisors
tends to be more successful in a northern
European–derived population, in which most
people have a convex profile with little or no
chin projection.
• Camouflage of mandibular excess by
retracting the lower incisors is rarely indicated
in patients of European or African descent but
can be effective in patients of Asian descent,
who often have prominence of the lower lip
more because of protruding incisors than a
large mandible. In these situations and with
other jaw discrepancies, it still is up to the
patient to decide whether tooth movement
alone would be successful treatment.
 Surgery
• Computer-generated simulation of the
posttreatment profile can greatly help
patients understand the differences among
alternative treatment approaches
• Advancing age is indicated by increased facial
wrinkles, looser skin in the cheeks and throat
because of loss of tissue in the deeper layers
of the skin, and decreased fullness of the lips.
• Until recently, face lift surgery approached
these problems primarily by pulling the skin
tighter. The emphasis now in improving facial
appearance in adults is on “filling up the
bag”—adding volume rather than decreasing
it.
• One of the advantages of mandibular
advancement surgery, and to a lesser extent of
maxillary advancement , is that it does add
volume and makes adults look younger by
doing so
• Genioplasty, the most frequently used adjunct
to orthodontics, also enhances facial
appearance by adding volume to the lower
face, but in addition it improves the stability
of the lower incisors and decreases the
chance of gingival stripping by adding bone in
front of protruding lower incisors, and so is
not just a cosmetic procedure.
• Surgical mandibular advancement tightens the
skin around the mandible, decreasing wrinkles
around and beneath the chin, which tends to
make the patient look younger
• Orthognathic procedures that decrease
volume (mandibular setback and superior
repositioning of the maxilla are the best
examples) improve facial proportions but can
make the patient look older because of the
effects on the skin.
• For that reason, almost all surgical Class III
treatment now includes maxillary
advancement, which often is combined with
mandibular setback in prognathic patients.
The goal is to correct the jaw discrepancy
without making the patient look prematurely
older.
• For some patients, maximizing the
improvement of esthetics requires facial
plastic surgery in addition to orthodontics or
orthognathic surgery
• Rhinoplasty is particularly effective when the
nose is deviated to one side, has a prominent
dorsal hump, or has a bulbous or distorted tip.
Deficient facial areas, such as the paranasal
deficiency that often is seen in patients with
maxillary deficiency, can be improved by
placing grafts or alloplastic implants
subperiosteally.
 Growth Modification

• If possible, the best way to correct a jaw

discrepancy would be to get the patient to
grow out of it. Because the pattern of facial
growth is established early in life and rarely
changes significantly, jaw growth in all three
planes of space can be modified, with a
combination of restraint of excessive growth
and stimulation of favorable growth.
• Greater growth modification is possible in
Class III than in Class II patients—just the
reverse of the possibilities for camouflage.
 Mini-Esthetic Considerations:
Improving the Smile Framework
• The primary goal of mini-esthetic treatment is
to enhance the smile by correcting the
relationship of the teeth to the surrounding
soft tissues on smiling.
Examination focuses on three aspects of the
smile:
• Vertical relationship of the lips to the teeth,
• Transverse dimensions of the smile,
• Smile arc.
 Vertical Tooth–Lip Relationships
• General guideline is that there should be at
least 75% display of the central incisor
• The amount of display is a function of the age
of the patient, with a peak at adolescence of
an average display of 85%, little change up to
about age 30, and then a gradual decrease as
aging lowers the lips across the anterior teeth.
• Exposure of all the
crown and some
gingiva is both
esthetically acceptable
and youthful appearing
• No gingival display is
less attractive,
although it is not
considered
objectionable at this
level by lay persons.
• C) There is agreement among laypersons regarding the
acceptable range of gingival and tooth display during a
posed smile. This girl shows 1 to 2 mm of gingiva, which is
the maximum acceptable amount on a social smile. (D)
Overlap by the lip of the cervical margin of the tooth by 1
to 2 mm is ideal. (E) Tooth coverage by the lip of 4 mm is
considered to be the maximum acceptable amount.
• If the tooth display is inadequate, elongating
the upper teeth improves the smile, makes
the patient look younger, and is the obvious
plan.
• Treatment approaches to accomplish this,
• In orthodontic treatment alone,
– extrusive mechanics with archwires,
– judicious use of Class II elastics to take advantage
of their tendency to rotate the occlusal plane
down anteriorly,
– anterior vertical elastics.
• Rotating the maxilla down in front as it is
advanced surgically can improve smile
esthetics, especially in patients with maxillary
deficiency
• A mild skeletal Class III
problem due to
maxillary deficiency, the
frontal rather than the
profile appearance was
(appropriately) her
major concern. (B) After
treatment to bring the
maxilla forward and
rotate it down
anteriorly, to increase
incisor display.
• Excessive display of maxillary gingiva on smile
must be evaluated carefully because of the
natural tendency for the upper lip to lengthen
with increasing age. What looks like too much
gingival exposure in early adolescence can
look almost perfect a few years later
• There are now three possible treatment
approaches to excessive gingival display due
to incorrect dental and skeletal relationships:
(1) intrusion of the maxillary incisors using
segmented arch mechanics,
(2) intrusion using temporary skeletal
anchorage, and
(3) orthognathic surgery to move the maxilla
up.
• Overgrowth of the gingiva may contribute to
the initial excessive display, and if so,
recontouring the gingiva to gain normal crown
heights is an important part of correcting the
problem. Laser surgery makes this much
easier and more convenient than previously.
 Transverse Dimensions of the Smile
• She [or he] has a broad, welcoming smile”
often is used as a compliment
• In patients whose arch forms are narrow or
collapsed, the smile may also appear narrow,
which is less appealing esthetically.
• In the diagnostic examination of the smile
framework, the width of the buccal corridors
was noted. Transverse expansion of the
maxillary arch, which decreases buccal
corridor width, improves the appearance of
the smile if the buccal corridor width was
excessive before treatment
• Too much expansion of the natural dentition
can produce the same unnatural appearance
of the teeth, so transverse expansion is not for
everyone.
• An important consideration in widening a
narrow arch form, particularly in an adult, is
the axial inclination of the buccal segments.
Patients in whom the posterior teeth are
already flared laterally are not good
candidates for dental expansion.
 Smile Arc
• The traditional guideline for placing brackets
has been based on measurements from the
incisal edge so that the central incisor bracket
is placed at about the middle of the clinical
crown, the lateral incisor bracket about 0.5
mm closer to the incisal edge than the central,
and the canine about 0.5 mm more apically.
• The usual problem is that the smile arc is too flat
• (C) and (D) One year later, after orthodontic (not
orthognathic surgery) treatment. The improvement
in facial appearance is largely due to better lip
support by the upper teeth that decreased the
paranasal folds and attainment of a correct smile
arc.
• If that is the case, putting the maxillary central
incisor brackets more gingivally would
increase the arc of the dentition, bring them
closer to the lower lip, and make the smile arc
more consonant with the lower lip.
• If the smile arc had been flattened during
treatment, step bends in the archwire would
be an alternative to rebonding brackets to
correct it. Repositioning incisors to obtain a
better smile arc may be needed in
orthognathic surgery patients, as well as in
patients who are to receive orthodontic
treatment only.
 Smile Symmetry
• An asymmetric smile sometimes is a patient’s
major concern. It is possible that this is due to
more eruption of the teeth or different crown
heights on one side, and if so, repositioning
the teeth or changing the gingival contours
should be included in the treatment plan.
• Greater elevation of the lip on one side on
smile, which is an innate characteristic that
cannot be changed, gives the appearance of a
cant to the maxillary dentition when it really is
symmetric. For a patient who complains about
smile asymmetry, this becomes an important
informed consent issue; the patient must
understand that the asymmetric lip
movements will not be changed by treatment.
 Micro-Esthetic Considerations:
Enhancing the Appearance of the
Teeth
 Micro-Esthetic Considerations:
Enhancing the Appearance of the
Teeth
Treatment plans for problems relating directly to
the appearance of the teeth fall into three
major categories:
• (1) reshaping teeth to change tooth
proportions;
• (2) orthodontic preparation for restorations to
replace lost tooth structure and correct
problems of tooth shade and color
• (3) reshaping of the gingiva.
 Reshaping Teeth

• Often, it is desirable to do minor reshaping of

the incisal edges of anterior teeth to remove
mamelons or smooth out irregular edges from
minor trauma.
• When minor reshaping is planned, it must be
considered when brackets are placed, and it
may be easier to do this before beginning
fixed appliance treatment.
 Changing Tooth Proportions

• Extensive changes in tooth proportions are

needed primarily when one tooth is to
substitute for another, and the most frequent
indication is substituting maxillary canines for
congenitally missing maxillary lateral incisors.
When a lateral incisor is missing, the treatment
alternatives always are
• closing the space and substituting the canine,
• prosthetic replacement of the missing tooth
with a single-tooth implant or fixed bridge
Technique for reshaping a canine
• If the gingival margin of the canine is visible
(which is undesirable when it is to substitute
for a lateral incisor), it can be concealed by
elongating the tooth and increasing the
amount of gingival reduction. Recontouring
the gingiva over the first premolar that
becomes a substitute for the canine also
enhances appearance.
• It requires significant removal of facial,
occlusal, interproximal, and lingual enamel.
The canine is normally a darker color than the
lateral incisor, and removal of facial enamel to
get light reflection from the facial surface as it
would be from a lateral incisor can further
darken the tooth. In some patients, composite
buildups or ceramic laminates are needed to
obtain good tooth contour and color.
• Closing the space and reshaping the canine to
look like a lateral incisor can provide an excellent
esthetic result, perhaps superior to an implant in
the long run. It is important to keep in mind,
however, that canine substitution works best
when the dental arch was crowded anyway. It
may not be compatible with excellent occlusion
and smile esthetics if closing the lateral incisor
space would result in significant retraction of the
central incisors
• In that circumstance, encouraging the
permanent canine to erupt into the lateral
incisor position, so that alveolar bone is
formed in the area of the missing tooth, and
then moving the canine distally to open space
is the best way to prepare for an eventual
implant. The implant should not be placed
until vertical growth is essentially complete, in
the late teens or early twenties, because late
vertical growth will produce an apparent infra-
occlusion of the crown on the implant
 Correcting Black Triangles.
• Decreasing or eliminating spaces between
teeth above the contact points, which are
unsightly if they are not filled with an
interdental papilla, can be accomplished most
readily by removing enamel at the contact
point so the teeth can be moved closer
together . Moving the contact area apically
eliminates much if not all the space.
• Care is required not to distort the proportional
relationships of the teeth to each other, and if
possible the progression of connector heights
should be maintained. Clinically, this means
that if the central incisors are narrowed, it
may be necessary also to slightly narrow the
lateral incisors and move their contact area
more apically to maintain a good dental
appearance.
 Interaction Between Orthodontist
and Restorative Dentist
• When the teeth are small or if tooth color or
appearance is to be improved by restorative
dentistry, during orthodontic treatment it is
necessary to position them so that the
restorations will bring them to normal size and
position. In modern practice, the restorations
are either composite buildups or ceramic
laminates, laminates being used particularly
when it is desirable to change tooth color and
shade in addition to the size of the crown
• There are two ways to manage the
orthodontic-restorative interaction. The first is
to carefully plan where the teeth are to be
placed, place a vacuum-formed retainer
immediately after the orthodontic appliance is
removed that the patient wears full time, and
send the patient to the restorative dentist for
completion of the treatment. A new retainer is
needed as soon as the restorations have been
completed.
• This has two advantages: The restorative work
can be scheduled at everyone’s convenience after
the orthodontic treatment is completed, and any
gingival swelling related to the orthodontic
treatment has time to resolve. It also has
disadvantages: Excellent patient cooperation is
required to maintain the precise spacing needed
for the best restorations, so the restorative work
may be compromised by tooth movement, and
the teeth are unesthetic until this is
accomplished.
• An alternative, which is most applicable when
composite buildups rather than laminates are
planned, is for the orthodontist to deliberately
provide slightly more space than the restorative
dentist requires to bring the teeth to just the
right size, remove the brackets from the teeth to
be restored, send the patient immediately to the
restorative dentist, replace the brackets the same
day after the restorations are completed, and
close any residual space before removing the
orthodontic appliance
• This has the advantage of
• eliminating compromises in the restorative
work, but the disadvantage that careful
coordination of the appointments is require
 Reshaping Gingival Contours:
Applications of a Soft Tissue Laser
• Appropriate display of the teeth requires
removal of excessive gingiva covering the
clinical crown, and is enhanced by correcting
the gingival contours. Treatment of this type
now can be carried out effectively with the
use of a diode laser
• A laser of this type, in comparison to the
carbon dioxide (CO2) or erbium:yttrium-
aluminium-garnet (Er:YAG) lasers also used
now in dentistry, has two primary advantages:
(1) It does not cut hard tissue, so there is no
risk of damage to the teeth or alveolar bone if
it is used for gingival contouring,
• A laser of this type, in comparison to the carbon
dioxide (CO2) or erbium:yttrium-aluminium-
garnet (Er:YAG) lasers also used now in dentistry,
has two primary advantages: (1) It does not cut
hard tissue, so there is no risk of damage to the
teeth or alveolar bone if it is used for gingival
contouring, and (2) it creates a “biologic
dressing” because it coagulates, sterilizes, and
seals the soft tissue as it is used. There is no
bleeding, no other dressing is required, and there
is no waiting period for healing.