CHAPTER 9 Special Considerations in Diagnosis and Treatment Planning 277 A B C FIGURE 9-38 A, The frontal smile relationship demonstrates diminished incisor display on smile. B, On sagittal smile, the flare and proclination of the upper incisors are apparent. C, Before treat- ment, a mild anterior open bite was present, and the flare of the maxillary incisors contributes to the open bite and the incomplete incisor display on smile. After interproximal reduction and retraction and uprighting of the maxillary incisors, the amount of incisor display increased. 278 CHAPTER 9 Special Considerations in Diagnosis and Treatment Planning D E F FIGURE 9-38, cont’d D, Interproximal incisor reshaping and retraction of incisors result in uprighting of the anterior teeth, reduced flare, and increase incisor display on smile.E, The saggi- tal smile demonstrates how uprighting of the maxillary incisor improves the smile arc relationship as well. F, This uprighting also results in closure of the anterior open bite. CHAPTER 9 Special Considerations in Diagnosis and Treatment Planning 279 B A C EG D F FIGURE 9-39 A, This 12-year-old, prior to treatment, had a nice smile with consonant smile arc but short incisal crown height, B, The close-up smile demonstrates the short crown height and slight gingival display on smile. C, Her initial intraoral image reflects the diminished crown height. In order to protect her already ideal smile arc, her brackets were place slightly closer to the gingival margin than standard protocol. D, Nearing completion of treatment, while the smile arc was ideal, the gingival hypertrophy secondary to oral hygiene issues (possibly exacer- bated by the bracket proximity interfering with ideal oral hygiene technique) created periodontal pseudopocketing as well as unaesthetic gingival display and form. E, The finishing close-up smile demonstrates the incisal edge placement and the gingival irregularities. F, Upon bracket removal, hypertrophy of the papillae and marginal gingival tissues were noted, resulting in poor gingival shape and contour as well as diminished crown height. Upon reflection, in a more contemporary approach, we might have considered crown lengthening prior to bracket placement in order to avoid this unfortunate sequel of orthodontic appliance treatment. G, Often brackets are removed, hoping a visit to the hygienist and time would resolve the tissues back to their ideal condition. In our experience, this often does not happen since the tissue is fibrotic and is hard to clean. In today’s world, parents are often beyond disappointed in the result. Either an immediate appoint- ment with the periodontist is indicated, or as in this case, a diode laser is employed upon bracket removal to recover an improved condition. 280 CHAPTER 9 Special Considerations in Diagnosis and Treatment Planning H J I K FIGURE 9-39, cont’d H, The aesthetic benefit is immediate, as is the elimination of pseudopock- ets and inflamed, hypertrophic tissue. Healing is promoted because of the tissue sterilization characteristics of the laser procedure as well. I, One week later, the inflamed gingival tissues were resolved and a more aesthetic and healthy soft tissue resulted. J, The final frontal smile. K, The final close-up smile. half-circular shape. The maxillary centrals and canines should protected as planned, but she had an excessively gummy smile. exhibit a gingival shape that is more elliptical. Thus, the gingival This aesthetic shortfall was secondary to the gingival inflamma- zenith (the most apical point of the gingival tissue) is located tion unfortunately seen in many orthodontic cases. The intra- distal to the longitudinal axis of the maxillary centrals and oral image (Fig. 9-39, F) permits a more detailed microaesthetic canines. The gingival zenith of the maxillary laterals and man- evaluation. Gross gingival inflammation was apparent, but dibular incisors should coincide with their longitudinal axis” gingival height was disparate, the gingival papilla proportions (see Fig. 9-31). were excessively large, and the zeniths individually varied. Recontouring gingival shape and contour now can be When faced with this situation, the frequent orthodontic action accomplished readily, in the orthodontist’s office if desired, is to remove appliances and immediately refer for cleaning and with a diode laser.3 prophylaxis, followed by observation for soft tissue resolution. The patient in Figure 9-39, A, chose to pursue orthodontic This may occur over time, but often the tissues are fibrotic and treatment at age 12 for correction of some spacing and slight do not recover as readily as we might wish, and a referral to occlusal discrepancies. Her close-up smile assessment (Fig. the periodontist is indicated. While controlling hygiene treat- 9-39, B) showed an ideal smile arc with complete incisor display ment would have been the ideal approach, this is not always but had slightly short crowns due to incomplete passive erup- possible in spite of all the promises the patient or parents may tion and had slightly more gingival display than ideal. Her deep give. The periodontal procedure is then met with resistance overbite was shown in her intraoral image (Fig. 9-39, C), as was because of fear of pain, expense, and further delay of the desired the short height/width ratio of the anterior teeth with some aesthetic outcome. In this case, we probed the pocket depths enlargement to the interdental papillae. Assessing the progress for assessment of removal of the excessive gingival tissues and of treatment after 9 months of full-fixed appliances (Fig. 9-39, immediately upon removal of appliances performed simple D and E), we noted that the vertical incisor position had been gingivectomy with a diode laser (Fig. 9-39, G). This removed CHAPTER 9 Special Considerations in Diagnosis and Treatment Planning 281 AB FIGURE 9-40 A, This patient’s smile line was asymmetric because of differential crown heights. B, Three weeks after soft tissue contouring and lengthening of the right central and lateral inci- sors, the smile was more symmetric and greatly improved. the excess tissue, cauterizing and sterilizing the ablated wound bracket position to the incisal edge or (2) position the bracket margin (promoting healing), resulting rapidly in the final out- in the center of the clinical crown, whatever its dimensions. come (Fig. 9-39, H and J). In this patient, positioning of the bracket a prescribed 4.5 mm When finishing the anterior aesthetic relationship within the from the incisal edge would place the bracket too close to the smile framework, the average location of the gingival margins gingival margin, potentially causing gingival overgrowth and should demonstrate a symmetric level of the margins of the oral hygiene problems. Positioning of the bracket in the cen- central incisors and a lower location of the lateral incisors and ter of the clinical crown (Fig. 9-41, B) would cause unwanted gain a higher and ideally symmetric level on the canines. The maxillary incisor intrusion and a reduction in incisor display patient in Figure 9-40, A, was treated to an excellent occlusal on smile. In this case, the decision was to improve tooth pro- and a good aesthetic result. However, the smile line was asym- portion through laser crown lengthening before bracket place- metric because of differential crown heights of the maxillary ment to maximize the chance of positioning the incisors in right central and lateral incisors, relative to the left side. Using their ideal vertical position (Fig. 9-41, C). the diode laser, the excess gingiva was excised on the right cen- Bracket positioning for optimal aesthetics. As orthodontists tral and lateral. Three weeks later, the smile was more symmet- diagnostically move away from the procrustean approach to ric and greatly improved (Fig. 9-40, B). diagnosis and treatment planning (every patient gets fitted to the same cephalometric analysis, and all patients have their Bracket Placement in Preparation for Changes brackets placed the same distance from the incisal edge or cusp in Gingival Shape tip, according to a chart), concepts of bracket placement also are When a dentist is preparing teeth for laminates, it is not uncom- evolving. Rather than bracket placement being a function of the mon to reshape and idealize the gingival heights and contours dental-centric preadjusted appliance demands, placement of with a soft tissue laser before final preparations are made and the maxillary and mandibular anterior teeth should be directed impressions are taken. In orthodontic treatment, because by concerns such as the following: orthodontists usually are not able to make contour or shape 1. How much maxillary incisor is displayed at rest (recall the adjustments, their recognition factors are low relative to these data on incisor display at rest and the aging smile)? problems. Orthodontists must be able to visualize the crown in 2. How much maxillary incisor is displayed on smile (also a ideal proportion before bracket placement and in many cases characteristic of the youthfulness of the smile)? shape and contour the gingiva prior to bracket placement. 3. The relationship of the anterior teeth to the smile arc. The patient in Figure 9-41, A, has a disproportionate 4. Crown height and width incisor proportionality. width-to-height ratio of the maxillary incisors. Most aesthetic 5. Gingival height and contour characteristics. dentists strive for a central incisor width-to-height propor- What is the process to determine the desired bracket place- tion of 8:10, and this patient’s incisors have the same width ment for each individual patient? As in the macroaesthetic and and height. This disproportion could be due to lack of inci- miniaesthetic treatment goal setting, a systematic approach sor height (gingival encroachment or delayed or incomplete to these microaesthetic considerations is needed. The authors passive eruption requiring gingival reshaping) or incisors that recommended the following sequence of measurements to be are morphologically wider than ideal in terms of crown shape made on the initial examination, recorded in the database pro- itself (requiring reshaping of the crown).