Beaury Lonceviry Trust SrReNoTH SESSION cna "Yc, witiam ainet, DS, FA.CD. and Michaol Gunson, DDS, MD. Dr. Arnett autem the Unie of Sothern Califia (USC) Dental Seo and Uniesiy f California at Las Angles (UCLA) nora and mail sure. His racic ited fal resnsacon ead gery and rear. He hat leaned neal and nearly oll ‘ec of orhpnahe suey and has published ramets ates Last yt he cova «Doak 1th Dr icant laughin eed Fail and Dental Planning for Onhodntis and Or St ‘eons Dr-Armat ssa pfs, Depa of Oral an alfacl Suyey;Lo Linda Unie nial eis profs USC enor ltr Scion of Oral ond Marfa Sur sy, UCLA anda inal profesor, Department of Oral and Mavic Steg, Une of “Tous Heath Sone Comer a San Ao, Gunn i 1997 rato te Universi of Califia at Los Angeles (UCLA) Dental Scho els cies il der an Spi Caren Ora ara Malet Surgery fom [UCLA Upon compen of Ws vaning, Dr. Cuomo prtne wh Dr. . Wiliam A= ret a The Cone fr Cnet aw ire Sara Barbar, Carin. Snes that nhs as "ce as Bon Hed w ogi surgery Dr Carson has cured ed pled search on the “surgical orton of pop, the media stent of mandible rst, the ‘untfain of bay, BO The malt Cooma Deniary RTOS Cl Ne“Te gol of this scion is pro- de ish i the mind of sme of denis’ premier educators. I this sue’ Dr G. Wiliam Arnett terits abou the importance of facial “aalss.The arte fllowed bya ‘uri in hich AACD Confer ‘ence Advisory Co-Chair Dr. Bran [aSage (BL) spss with Dr Ame (GWA). 18 hop tha this section tell provide how of shat at eee ca expect Ns gwen Dr. Aree presens a course com proensveeshes atthe AACD's 22nd Avmal Scenic Sesion in ‘San Diego, Carta Assrnact ‘Occlusal conection should pro luce precise function, but other goals must also be achleved. The ‘emtton should be placed into a healthy periodontal poston with ‘ou scrcng facial balance. Facial diagnosis stats with gen cal dents. The general dent In oflen the fist dental prosional, wo can afer diagnosis and et ‘ment planning for fail sues. The severly af the oclsal and facil problems should be evaluated and titer tated by the general den fst or refer for muliiaipinry treatment witha prothodontisy n ombodontst, andjor an orl and ‘maulofcial supron, When oc lusal disharmony exis the fail lnplicaions of och teatment must be understood to hep guide treaumentplnning facial ether ae ignored, he dental and ocusal ‘nestment els might be approp ae but the dentist rks main ing or worsening daha mony. However If we undestand facia ethetics the overall eatment ‘outcome wl be improved Denitey has become the pric mary vehide for fal exhete en hancement for patient in thie 208 ‘hough 40s, Facial enhancements may be as simple as cosmetic ve ‘ner of 3¢ complex 38 total facial reconstncion via ethognathic surgery These wo extemes fet ‘ment must balance occu change with i eects on facial execs Examination ofthe patient’ och sion reveals the noed for chang, hil facial examination dictates to the inician how ico be restored Alton ofthe occasion should have as 2 goa the reves of nega the fal tee and. maintenance for enhancement of positive ats This goal cannot be achieved with coutacompleteundersanding ofthe patent’ exsting fl esits porto ‘oeatment. This ale presents the ‘ea face a ide and pal foro lor modietion, Wher occlusal disharmony exis, the facial implications of ecusal treatment mst be derstood 0 help guide treatment planing. Iytmopuction Diagnosin.teatment planning and ection ate the sep involed fn soccenol conection of dental robles. Dag Is defining the robem: ween: plain is bee fon diagnosis and ie the rocese of determining. which changes. will eliminate the problems veument executing the plan, The eradication ‘ofthe patent het complaints of Paramount importance in guiding allphase of weatment ‘The treatment planning of facial chet changes can be dic pecially in terms of integration with ‘te conection, The asuumption that bite conection leads to one. facil estates began with onto Eh ool of Cosmetic Dent + FN I005 onties Unfortunately, conection ofthe bite doesnot always ead to “conection, or even maintenance of facia esthsice "At times nthe ze w coneetoeelial and dental disharmony, facial decline occurs. ‘The most common source offal Fo 2005 "igure 5 Fail photo profile dled lip with wa bite: Nowe the ip and mentalist. (eoreantser tet con up ging Negmen” ‘Som Chaturh C tion, Lip incompetence is suained ‘ome fom rene to closed po Son. Thue sigs of rain are chin Aauening ip Hatening, and nasal bate narowing Menalis and lip sain with ip lose indicates ether 3 longs tal eight or shor lips (usually ‘pper ip), When the lps are eda dan inthe relaxed postion, ebher the bite is deep andor the skeletal length is shor. Porte ANcat This angle (Fg 1D) is formed by connecting sf tissue gabe, su ssl, and of tise pogonion "=" {hss ocusion presents oa lal angle ange of 165¢ 10175." Chas I anges ate less than 165° Dental procedures should genet ally adress the cosmetic imbalance ‘xablished withthe measurement, ‘he profil angle is the most impor tant key tothe ned for anterior pos terior akletal conection. When va uss are below 165° or above 175°, sleletalmaloccasions nesting surgery ae probably the cause ame 21 + Nonberdgue 4 acl photo, profile eos with wa bis Note the act profil ange bfore surgery the ‘her lng anda ald amount of sent ag. Tew alindateoselalCla 1 latonip ‘tk mend ypoplsi: (forename “tion, Drm on Mang Sans ‘ions ca) Nouns Ana + Amero hme. Chedone scent rege Iuesnse Tain) esenelly— Tsetorewintctrame”” Gon Ghbeos onmieon hp . se eee eae omthan ikl (12020 Gagne hire ype of Cl Ths dimension cn hang not sam)" UL ecient chekbones may core Th denon sa ge noe un hone aye ‘ably with prosthetic, orthodontic, ‘+ The larger the overjet brshitclhioercineopas ae tse iar "tae hemo aon of ‘Hewes a fen de {he hnteiocpsron positon or thematily incor wil be hr an le inna oe aalayseoe em operngieso-_—_ n.Chcbone conor se teh" A pecedes shou ange == oat oem ee metal dviale range of 85° t© (gear 105"), reaction of anterior Nasa Paocron 105°." Female patient wil wily teeth should be aolded in Wea The gal groecon (Fig 1D) be more obtuse within this Tg ment plsnning Lewis = HH005 amare romeo how be Fe a ee nchane ROM will become adversely rom sega nasal sip isnoxmally 141017 sment planning to cone achiewe nent withiiprevacion.Pesentlin- SIG Neu meeton ani thisanpeincide he following: ed Knowledge of how ipa respond ry vey anes poner + Exiting nasolabial angle taney morn fon nate ae ‘he eth dctates a conservative a> Gated tha long nasal projection, + Change the crown postion ne ect Yoach when large movements ae mormon Semple “mos incr sn Coaroun ‘vei and ove. Hove the crown postion change Cyumstone Contour The throat engin (Fg 1) fom neclethrost pont tothe sot sue lle the upp ip pos ‘A normal cheekbone i an ant yeion shouldbe characeize’ a tion Tens lps may move ‘orficing curve tht sas athe engl short oF norma length smote poweriony wih 1th ygomatie arch going forma and en ee movement andes aniein. own, ending ust behind the Base acne’ treet Tan Faccd ip may move les with of the nose (Figs IC & 1D). THE er postion. lng throat length anesior and poseior oath cheekbone point ia distin eght Found with Cas Il clon nh movement cofeomtou ofthe cheekbone “Vehamei+Nanbed SSS = Te om Cosme Dentry 29Exaninaton ‘Nonnal Values Patient, Preoperative [Patent Postoperative Nasal bridge midline | midline rine unchanged ‘Nasal tp mine mie midline unchanged Piru iin lie midline nchonged Upper incisor midline [mine midline unchanged Lower incisor mating [wine (05 mm fe midline chin mine rine (0.5 mm et idling axillary canine evel [evel (0.5mm down night [level Mandibular canine evel [tevel (0.5mm down on agit [level (Chin evel level 0.5 mm down ont” [evel ower 13 o- @rm om 8 mr Upper Tip feng 19-2 mm 20 mm 20m Lower ip length 2mm 2 mm 5 mm Intra gap 1S, females male [9 mm 3 rm Upper incisor top [1-5 mm, female> male 7.5 mm 35 mm relaxed Upgerincsorlp— [ue connie -2am [2S rm ar Tom gna closed ie no sain wane pean Upper incorcronn [9.5 = 11.3 mr 95 om unchanged height Praile angle Female 150 18" Male ‘Nasolaia angle Female To To Mate a5 15 Cheekbone conour ‘ound wah dine height of contour rounded wih diner height of contour wading Nasal projection 15-1 mm 17 im Thzoat lengh contour [5264 mm 7 mm 35 mm without 98 ll ag? no sg Te Verical Line Female mm Tam Uppertip 2.5mm fmm 2 mm lower ip 13 mm 16mm" ‘i chin -45--0.7 mm Male Uupperlip 16-5 mm lower ip 12-322 mm hin 5-3-1 7 mm Table 1 Facial examination norms and preoperative and pasiopraie vlus for patient devas bora al) 30 The > Raer?Sr aetna, em SSY| aw — igure 5: Caphalomerc treatment plan. Changes are based on opting facial appearance while caren he bite. The ‘ginal rcng nach and th ie ltl and fal change ar nr. The ie ndates eaten I necesry he face india wth te conve (opi mai nd Saapenet Speer) ‘ates mandibular proton rather csr support for the upper ip, an waublte in CR which was wsed 0 than mail retrson. ‘aright upper lp, thick upper lip, take photographs a lateral cep fan reided upper incor: When lometie sadiogaph; TM) tome- ‘TaueVernen Lint ‘nice erion i dignosed he gaph andl fia measurements ‘Thue eral line (TVL) measure TVL ie moved Ito Sram antesowy- [Table 1). Goakdireed ueatment ments" are upper lip, lower ip. the upper pis anterior the TVL___planningwas followed inorder .o and chin projections (Fig 1D). They by «2.5t0 650mm forfemalesand core the bite represent the sum of the dental of 1.6 wo +30 mm for males. The + produce fal balance + place the eth na ea peiodontal postion skeletal poston plus the thickness foyer lip i +5 to «3.3 mam tothe ‘ofthe overying sof tsie. The TV. TVLfor females and-1.2 1043.2 for isdawm through subnasleperpen- male, The chin (of sve pogo ‘ular co natural ead positon. ion) ispesteror tothe TVLby-# 5 + ens longer stably Aton sible feauenty wil fon 7frfemalrand-5.340-17for — improve and proet To func osioning of the TVL they 2 cae repo i provided below. protect he is Sot nonymous The TV. mus be aa dagoss Was used to esa ae moved forward in aes. of msl” igh ne real eaten plan. Dla goeyrachair tay teusion. Miface resin the patents sheet discrepancies th ondonic tooth movement Acne by a longappessing nose ve Sta depresed or Bat oie rims CSE REPORT in any plane of space. Ondo ‘heck bones subpuphe and alar ‘The patent presente to our af Preparationvadcidony toward Tooth alignment ard segmental ach bases, Additional festures of mid- ces for consultation a age 20. Her reparation, sto accomplish the face retmsion may include poor in-sugcal consultation incded 3 Vota 27> Ramer — Fa Z005 «The furl of Cosmetic Deny 37foals of healthy periodontal posi- Aioning and maximum dena Aigtaion a sng ‘The Ths were symptomatic for Painfal clicking andthe patent complained of masseter and tem poralis pai, Three months pir 0 surge she was placed on medics ‘ons and pln therapy in onder to prevent condyar changes. Medica tions inluded Doxyeyeine 100mg, Feldene 20mg, amitpsine 10mg, vitamin © 500mg, and vitamin E ‘oa, ‘fier onhodontc_ preparation, presurgalecotds were obtained. A ‘ew Cor bite war sed forthe lt sal cephalometse radiograph, the “TJ tomogaphs, the fal exami- raion, and the model mounting, ‘The wae bit ests the conten cy and accuracy of ll cord TMI ‘omographs revealed small condylar Dads wth sone anterioeHatening but nice cortical outing cei Ewsananon ‘Ccdusal examination revealed a transverse constriction from canine to second mola when placed into 4 Glass I relationship (33 mm to 1.7 mm, respectively). The patent leo had »tworplne occasion with breaks between the lateral incor and the cnines, CR models and headfilm measurements revealed 2 sigicant Clas 11 malccason With 9 mm of vet and 2 mm of owsbite acs Exar On fiona ficial eeaminaton, ‘he nasal tp and the upper incisor midline were onthe facia etc ais as defined bya line though na ‘a bridge midline an the pikum (ofthe upper lip. The mandibular and chin midlines were mm to ‘he left ofthe facia vera a ie ‘The masilry and mandibular nines were canted down on height yo. mm (Fig2). The lip lengths were measured as owl. The incor to ipl (ie 2) and incest ipamile measurements wee longa 75 mm and 25 of ging, especively The cheekbone contour was ex cellent with a rounded, distinc height of eontour (Fge 2-4), AL dosed ip postion thee was wile menais and lip stain (3) In profile she hada shor throat length wth mil submental sg Her ile angle was 158" and he love lip and chin excessively reruded ffom the tue vet ine (3 mm and -16-mm, respectively) Gow Drie Tener Pas ‘Aer cus and fila ‘the goal-irecte treatment plan in ‘ded a mulisegment LeFort Lo seotomy, bilateral sagital split ose tomes anda sling geniopasy ‘The segmentation ofthe maxilla Provided adequate wid and arch form comeson. Bimal surgery permited conection of the caine ‘ats t alo allowed counterclock ‘wise rotation ofthe aclu plane, which provided chin projection Without disturbing her nasal base “The exesse Inekor and gga Show was coneced by anterior ma lary impaction. Ovebite overt and mines were cored and he remaining chin deficiency was ove come with a genioplasty (Fp 2-5, righchand photos). ‘The patient was maintained on ‘he TMI medications fra fll year “32 The Jounal of Cometic Densry «FT IO05 afer surgery 10 prevent conéylar ‘hangs. Eightoen months ater su 25, er oclsion remains sable Sand hr fac esthtc esl ie excel Tent (h2-5ighthand photos). Conciusion Dents genealy use occu factors t diagnose and eat ma ‘occasions, These occlusal fons Include oveyet, canine occkson, and molar oelsion, Many dents, Ihowever, donot consider facial al nee in thir teaument planning ‘Thisarce presensan organized, comprehensive approach 10 fii anal forthe general deni. F dal diagnosis as described, i sed to guid pure cosmetic changes orto ‘erase the facial changes that oc cur with dental oclsal changes References et, epi atl te 3 ‘hing Fon) One nt stern. 98 et He alo Flinn fa Oa Dr Drip yanoai2 0 tse pam aL in Or “rm oe 4 os a ‘S olomogni my Age re Sensatron 9 We le ‘ay uel ngs dnc ‘Moos rd Oi Shsse toe ‘re ier 54724 19 7 Poke nan i ede ‘en pansy a Ds rash 8 ome 1» NaberSots se ‘opoyaesab4 oe tn oapaomete np A) Fanta 023.4 58 Tonto ea ‘i net One 50) 20500, Ut ge woe malay cor ‘emi a) Oo 42373809, (Sm rd rfl Ot het Mean RE al ad ‘et oo ri da + Volume I Numbers Be The FUTURE of Dentistry... Tova! Th Une Retin La Trang Pogo HANDS-ON and Win micRoscones ‘ie cocld yu Bic om Topi by High F< DOS seceded Mater SACD Kew das lied setng Aenea Tegsoionenies ‘egister olay! Viscum ghfltdscom formore information ‘te dates o404255-29%6 Tal 2005 + The Jounal of Cosmetic Dentsry 33ae view with G. Willi = Yaron Lesage, DDS De LeSage graduated mag cm ae ‘and resid he Omicon Kappa pon ‘Honor Dewal Society Aan! fm the Univesity of Mayand Dental Sl 1983. The fer and dtr of the UCLA dest Contin and on ADA Seminar Snes spear, he paces ‘he and mension Bae ‘ely Hil Cfo Dr Lesage betes and gies handean rogram nal res of cme dns 1 bth naoly ar imtrntionalh Ie san Acid member an allow of the AACD aa Few ofthe ACD, ‘Since 195 he has oon an Acrdatin famines a are Cha of the Flush Commi As casas dey aloft it ou dag and reatment © the et ips and sme But as we areal ry, he ices of the sale mao depends onthe se pxedre ha on poet altering the cecon Ant an stub be uno the eat scheme! Further mores yous rough ahd, i wl he echoal changes fect. ‘hepa face? I ink we wl al being mae on fai nay and its sigan nxn sie mater povednes You aes compre esi facial rat enalhis—shere a the fa’ ede fol shee ora sstemaiway tonal falas? What te ook eas might readers expe fier ain mare ladon te nership of cal estat, clon, end att stato? Fgures IA-1D inthe preceding ate canbe lion o guide ala analysis Additionally we have published comprchensive papers and a tebookom al apes offal anal" ‘ow mrtond thar al examination sould be code in cnr tion (Ci). Cau you abort on wb Ceca nour ana? The repo (dn putin and eral igh) eae her the ins re seat sas, des at hae be he string positon fr facial ‘ana? ‘Surgeons, inf do fallout reconssuction by operating onthe jaws CR must be the stating point for that proceso provide secure Alagnosis and able Tal funtion ‘ou sae the outer plan shld ei yh aia examination, Dees that meon eset paramere sould ist be anahed and acount or ‘nyo ewarmen panning proves? Bite examination rewals malocuson. The face reveals how to comet, the maloclsion. An example ofthis i Clas It maloclision he “upper arch an be reacted othe lower ach an be advance to or rec the occlusion ut te facial ests willbe very ferent. The facial ‘examination evens which testment comet. "WH he jal a Cosma Deity «AN2005 i 2 = air