Global Analysis Diagnosis and Sequenced Treatment"Global" Analysis Diagnosis and Sequenced Treatment...
Transcript of Global Analysis Diagnosis and Sequenced Treatment"Global" Analysis Diagnosis and Sequenced Treatment...
"Global" Analysis Diagnosis
and Sequenced Treatment
coredentistry.com
Jeff Rouse, DDS
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