Centennial special article
Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning

https://doi.org/10.1016/j.ajodo.2015.04.030Get rights and content

Highlights

  • Good data on soft tissue maturation and aging in the perioral area are available.

  • Both hard and soft tissues should be considered in treatment planning.

  • Each patient's posttreatement soft tissue profile should be age appropriate.

The approach to orthodontic diagnosis has changed gradually but steadily over the past 2 decades. The shift away from diagnosis based entirely on hard tissue evaluations has been a result of a broadened recognition of the importance of facial and smile appearance to our patients, and how they change over time. The purpose of this article is to describe and illustrate the integration of the new soft tissue paradigm into long-term treatment planning, with a focus on the esthetic goals of treatment.

Section snippets

Systematic evaluation and treatment goal setting

Soft tissue changes occur over time, and it is usually the orthodontist who best understands the comprehensive principles of dental and skeletal development, maturation, and aging in addition to the many other facets of dental practice.

The 12-year-old girl in Fig 2, Fig 3 came with a chief complaint of “the dentist said I needed braces” because of her Class II deepbite malocclusion. Although correction of her malocclusion was the reason for seeking treatment, she obviously exhibited an

Treatment plan

In addition to correction of the functional issues of the Class II deepbite, the esthetic treatment plan is determined by esthetic issues (primarily the excessive gingival display on smiling) coordinated with the protection strategy (maintain the consonant smile arc).

Let's revisit the etiologies of the gummy smile in comparison with this patient's clinical examination. This problem-oriented and goal-oriented approach to the esthetic problems results in the clinical examination and a biometric

Treatment summary

Our treatment consisted of fixed appliance therapy combined with growth modification (high-pull headgear) to correct the Class II malocclusion. The deep overbite was approached with reverse-curve mandibular archwires to extrude the posterior teeth, thus lengthening the lower facial height. The improvement in gingival display on smiling was a result of lip growth, increased crown height supplemented with periodontal crown lengthening, and axial uprighting of the maxillary incisors (Fig 10, Fig 11

Conclusions

There are really 2 major points to be made here. First is the importance of looking at the patient clinically at the beginning of developing our diagnosis and treatment plan. In fact, this assessment has been practiced for quite a long time; clinicians have drifted back to it in practice, and it has just slowly formalized. As a resident, I remember that many of my teachers referred to the “window-shade diagnosis,” the act of holding an actual cephalometric head film (not digital), untraced, up

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