Orthotown December 2020 - 32

(Fig. 9). In her case, it was not.
Step 4 is to determine the length of the
central incisor (Fig. 10), because it is the
central focal point of the smile and when
doing comprehensive dentistry, all other
tooth lengths and proportions should be
based off the size and shape of the central
incisors. In this case, her left central incisor
measured 10mm (normal) and her right
central incisor was 9mm (short).
Step 5 is to determine whether the
CEJ is palpable within the sulcus with
an explorer (Fig. 11). If the CEJ is not
palpable, then by definition the patient has
altered passive eruption,1 the incomplete
apical migration of the dento-gingival
complex, and will require aesthetic crown
lengthening with ostectomy to establish
proper tooth height.

Fig. 9

Fig. 11

Fig. 12

5 CORE QUESTIONS

Reviewing the findings (Fig. 12)
*

*

*
*

*

The patient's lower facial height
was longer than her middle facial
height. This can be an indicator
of vertical maxillary excess or just
a " tall " mandible. To make this
determination, we look at the amount
of incisal display in repose and in
full smile. If both are excessive,
the patient probably has vertical
maxillary excess. In this particular
patient, the upper lip was short due to
a history of chronic nasal obstruction
and mouth breathing. She also had a
tall anterior mandible.
As previously mentioned, her upper
lip was slightly short and hypomobile
due to her guarded smile and recent
history of receiving Botox injections
in her upper lip.
Her gingival line was not level, so
orthodontic treatment was indicated.
Her left central incisor was a normal
length (10mm); however, her right
central incisor (9mm) would need to
be crown-lengthened or orthodontically intruded to provide gingival
symmetry.
Her CEJ was detectable within the
sulcus, so she did not have altered
passive eruption.

32

Fig. 10

1. Face Height: 58.65 (1:1.2)
2. Lip Length/Mobility: 18mm/5mm
3. Gingival Line: Not Level
4. Tooth Length: 9-11mm
5. Feel CEJ: Yes

Diagnosis
*
*
*
*
*
*
*
*
*

Class III skeletal pattern.
Maxillary AP deficiency.
Maxillary transverse deficiency.
Bilateral posterior crossbite.
Multiple missing teeth.
Multiple questionable restorations.
Short upper lip.
Hypomobile upper lip.
Long anterior mandibular height.

Original treatment plan
*

*
*

Dentist to remove old restorations,
refresh preparations and
provisionalize with lab-fabricated
temporary restorations and
permanent cement.
Orthodontic appliances to prepare
patient for orthognathic surgery.
Surgical maxillary expansion and
advancement with vertical chin
reduction.

*
*

Complete orthodontic treatment.
Extract UR6. Implants UR6,
UR5, LL6, LR5.
* Final restorations.
Unfortunately, the patient was vehemently opposed to any orthognathic surgery,
so a revised treatment plan, using surgically
facilitated orthodontic treatment (SFOT) to
add facial bone to the maxilla and attempt
as much alveolar expansion as possible,
was devised.

Revised treatment plan
*

*
*
*

Dentist to remove old restorations,
refresh preparations and
provisionalize with lab-fabricated
temporary restorations and
permanent cement.
Orthodontic appliances to prepare
patient for SFOT.
SFOT with periodontist.
Complete orthodontic treatment.

DECEMBER 2020 // orthotown.com

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