Sequencing the planning process

Historically, the treatment planning process in dentistry usually began with an assessment of the biology or biological aspects of a patient’s dental problem. This could include the patient’s caries susceptibility, periodontal health, endodontic needs, and general oral health. Once the biologic health was reestablished either through caries removal, modification of the bone or gingiva, endodontic therapy, or tooth removal, then the restoration of the resulting defects would be based upon structural considerations. If teeth were to be restored or repositioned, the function of the teeth and condyles would be of paramount importance in dictating occlusal form and occlusal relationships, respectively. Finally, esthetics would be addressed to provide a pleasing appearance of the teeth. However, if the treatment planning sequence proceeds from biology to structure to function and finally to esthetics, the eventual esthetic outcome may be compromised. We proceed in the opposite direction. That is, we start the treatment planning process with esthetics and proceed to function, structure, and finally biology. We do not leave out any of the important parameters; we simply sequence the planning process from a different perspective. We choose this sequence because the decisions made in each category, especially esthetics, directly affect the following categories.

Beginning with esthetics in mind

When beginning with esthetics, we must begin with an appraisal of the position of the maxillary central incisors relative to the upper lip ( Fig. 1 ). This assessment is made with the patient’s upper lip at rest. Using a millimeter ruler or a periodontal probe, we determine the position of the incisal edge of the maxillary central incisor relative to the upper lip. The position of the maxillary central incisor can either be acceptable or unacceptable. An acceptable amount of incisal edge display at rest depends on the patient’s age. Previous studies have shown that with advancing age, the amount of incisal display decreases proportionally . For example, in a 30-year-old, 3 mm of incisal display at rest is appropriate. However, in a 60-year-old, the incisal display could be 1 mm or less. The change in incisal display with time probably relates to the resiliency and tone of the upper lip, which tends to decrease with advancing age.

This 35-year-old adult female showed about 3 mm of her maxillary central incisal edges with her lip at rest ( A ). However, she showed excessive gingiva when she smiled ( B ). Her occlusion was satisfactory, and she did not need orthodontic treatment ( C ). Her maxillary crown length was short, but the sulcus depth was normal ( D ). Sounding of the bone ( E ) showed that she had altered active eruption with the bone levels located at the cementoenamel junctions. A stent representing the desired crown length ( F ) was placed onto the upper teeth, and a gingivectomy was performed at that level ( G ). Then, a flap was elevated ( H ) showing the bone near the cementoenamel junction. The bone level was moved 3 mm above the desired gingival margins ( I ). After 5 years posttreatment ( J ), not only is the tissue healthy, but the ideal amount of gingiva is showing at rest ( K ) and during smiling ( L ).

If the incisal edge display is inadequate ( Fig. 2 ), then a primary objective of interdisciplinary treatment may be to lengthen the maxillary incisal edges. This objective could be accomplished with restorative dentistry , orthodontic extrusion , or orthognathic surgery . Choosing the correct procedure depends upon the patient’s facial proportions, existing crown length, and opposing occlusion. If the incisal edge display is excessive ( Fig. 3 ), then an objective of treatment could be to move the maxillary incisors apically either by equilibration , restoration , orthodontics , or orthognathic surgery . The selection among these disciplines again depends on the patient’s existing anterior occlusion, the patient’s facial proportions, or both.

This adult female lost her maxillary incisors in a childhood accident and was wearing a maxillary removable prosthesis ( A ). When smiling, her maxillary incisors were in the correct relationship relative to the upper lip, but the incisal edges were above the posterior occlusal plane ( B ), giving the patient an anterior openbite. Her past dental care was sporadic with decay and attrition noted in several areas ( C ). She had maxillary retrognathia ( D ). Orthognathic surgery was planned to move the maxillary posterior teeth apically to close the openbite but maintain the level of the maxillary incisal edges ( E and F ). A diagnostic wax-up ( G ) was used to fabricate provisional crowns, which were cemented ( H ) the day before jaw surgery. Orthodontic appliances were placed immediately before the surgery to stabilize the jaws after surgery ( I ). Implants were placed in the lateral incisor regions ( J ) and restored with a four-unit implant-supported bridge ( K ), which improved the patient’s smile ( L ).

This 30-year-old female was concerned about her “gummy smile” ( A ). She showed 5 mm of gingiva when she smiled, but the width-to-length relationship of her maxillary central incisors was ideal ( B ). She showed 8 mm of her maxillary incisors at rest ( C ) and, therefore, was diagnosed with maxillary alveolar hyperplasia. Orthodontics was used to coordinate the midlines ( D ), and maxillary impaction surgery was used to shorten her upper facial height and reduce the amount of gingiva. Her final occlusion ( E and F ) was improved significantly, and 5 years after orthodontic treatment, her smile still looks excellent ( G ) and her occlusion has been nicely maintained ( H and I ).

The second aspect of esthetic tooth positioning to be evaluated is the maxillary dental midline. Recent studies have shown that lay people do not notice midline deviations to the right or left of up to 3 or 4 mm if the long axes of the teeth are parallel with the long axis of the face . So, perhaps the most important relationship to evaluate is the medio-lateral inclination of the maxillary central incisors. If the incisors are inclined by 2 mm to the right or left, lay people regard this discrepancy as unesthetic . A canted midline can be corrected with orthodontics or restorative dentistry . Usually the choice depends upon whether the maxillary incisors will require restoration.

Beginning with esthetics in mind

When beginning with esthetics, we must begin with an appraisal of the position of the maxillary central incisors relative to the upper lip ( Fig. 1 ). This assessment is made with the patient’s upper lip at rest. Using a millimeter ruler or a periodontal probe, we determine the position of the incisal edge of the maxillary central incisor relative to the upper lip. The position of the maxillary central incisor can either be acceptable or unacceptable. An acceptable amount of incisal edge display at rest depends on the patient’s age. Previous studies have shown that with advancing age, the amount of incisal display decreases proportionally . For example, in a 30-year-old, 3 mm of incisal display at rest is appropriate. However, in a 60-year-old, the incisal display could be 1 mm or less. The change in incisal display with time probably relates to the resiliency and tone of the upper lip, which tends to decrease with advancing age.

This 35-year-old adult female showed about 3 mm of her maxillary central incisal edges with her lip at rest ( A ). However, she showed excessive gingiva when she smiled ( B ). Her occlusion was satisfactory, and she did not need orthodontic treatment ( C ). Her maxillary crown length was short, but the sulcus depth was normal ( D ). Sounding of the bone ( E ) showed that she had altered active eruption with the bone levels located at the cementoenamel junctions. A stent representing the desired crown length ( F ) was placed onto the upper teeth, and a gingivectomy was performed at that level ( G ). Then, a flap was elevated ( H ) showing the bone near the cementoenamel junction. The bone level was moved 3 mm above the desired gingival margins ( I ). After 5 years posttreatment ( J ), not only is the tissue healthy, but the ideal amount of gingiva is showing at rest ( K ) and during smiling ( L ).

If the incisal edge display is inadequate ( Fig. 2 ), then a primary objective of interdisciplinary treatment may be to lengthen the maxillary incisal edges. This objective could be accomplished with restorative dentistry , orthodontic extrusion , or orthognathic surgery . Choosing the correct procedure depends upon the patient’s facial proportions, existing crown length, and opposing occlusion. If the incisal edge display is excessive ( Fig. 3 ), then an objective of treatment could be to move the maxillary incisors apically either by equilibration , restoration , orthodontics , or orthognathic surgery . The selection among these disciplines again depends on the patient’s existing anterior occlusion, the patient’s facial proportions, or both.

This adult female lost her maxillary incisors in a childhood accident and was wearing a maxillary removable prosthesis ( A ). When smiling, her maxillary incisors were in the correct relationship relative to the upper lip, but the incisal edges were above the posterior occlusal plane ( B ), giving the patient an anterior openbite. Her past dental care was sporadic with decay and attrition noted in several areas ( C ). She had maxillary retrognathia ( D ). Orthognathic surgery was planned to move the maxillary posterior teeth apically to close the openbite but maintain the level of the maxillary incisal edges ( E and F ). A diagnostic wax-up ( G ) was used to fabricate provisional crowns, which were cemented ( H ) the day before jaw surgery. Orthodontic appliances were placed immediately before the surgery to stabilize the jaws after surgery ( I ). Implants were placed in the lateral incisor regions ( J ) and restored with a four-unit implant-supported bridge ( K ), which improved the patient’s smile ( L ).

This 30-year-old female was concerned about her “gummy smile” ( A ). She showed 5 mm of gingiva when she smiled, but the width-to-length relationship of her maxillary central incisors was ideal ( B ). She showed 8 mm of her maxillary incisors at rest ( C ) and, therefore, was diagnosed with maxillary alveolar hyperplasia. Orthodontics was used to coordinate the midlines ( D ), and maxillary impaction surgery was used to shorten her upper facial height and reduce the amount of gingiva. Her final occlusion ( E and F ) was improved significantly, and 5 years after orthodontic treatment, her smile still looks excellent ( G ) and her occlusion has been nicely maintained ( H and I ).

The second aspect of esthetic tooth positioning to be evaluated is the maxillary dental midline. Recent studies have shown that lay people do not notice midline deviations to the right or left of up to 3 or 4 mm if the long axes of the teeth are parallel with the long axis of the face . So, perhaps the most important relationship to evaluate is the medio-lateral inclination of the maxillary central incisors. If the incisors are inclined by 2 mm to the right or left, lay people regard this discrepancy as unesthetic . A canted midline can be corrected with orthodontics or restorative dentistry . Usually the choice depends upon whether the maxillary incisors will require restoration.