DTUS0710

f CT page 1C can be increased or how much free- way space can be decreased without interrupting the patient’s true physi- ological rest position. Concerns about changing the entire arch to effect anterior defects are unfounded for two reasons. First, the newly diagnosed mandibular position is verified as correct by using an orthotic before anything is done to the natural teeth. Secondly, this technique of treating a gummy smile is based upon opening the bite. Therefore, when porcelain is added to the full arch to increase vertical dimension, it involves little to no destruction of the natural den- tition because the restorations are placed over the occlusal surface. In the author’s experience and as illustrated in these cases, once PRP of the mandible is established, the increased teeth-to-gum ratio is sig- nificant prior to the removal of any gum tissue. It is prudent to mention here that if the patient’s PRP does not differ significantly from habitu- al after TENS relaxation, very little change in vertical dimension would be available for this procedure. Use of the Golden Proportion to establish a pleasing esthetic effect has been seen in art, architecture and various scientific fields for cen- turies and used in dentistry for at least 25 years.6 Like occlusal philosophy, some question its validity.7,8 However, it is used by many today in plastic surgery, orthodontics and esthetic dentistry as an element of treatment planning of facial esthetics and, in the author’s experience, patients are highly pleased with the outcome. Calculations utilizing the Gold- en Proportion equation can also be applied to tooth shape and will show whether the “golden” vertical index can be reached through a combina- tion of bite correction and gingi- vectomy. These simple calculations indicate whether the vertical length of the patient’s smile will be more esthetically pleasing after the cor- rections have been made. (Width of central incisor) ÷ 1.618 = golden length of cen- tral incisor (Length of central incisor) x 1.618 = golden vertical index Based on these two calculations, an orthotic in the optimal bite posi- tion for both esthetics and function can be fitted for the patient’s upper teeth. The orthotic is worn for a peri- od of approximately one month to be certain that no headaches, neck pain, grinding or chewing issues ensue. This period also provides the patient with time to become psycho- logically accustomed to the addi- tional tooth length that shows prior to the gingivectomy and application of veneers. If the patient is dissatis- fied with the length-to-width ratio of the teeth in the orthotic, adjustments can be made to the orthotic before beginning the procedure. Correcting the bite before per- forming a gingivectomy can offer a greater esthetic result, significantly reducing the amount of gum tissue that shows before a gingivectomy is performed. It should be noted that placement of porcelain on the molar teeth to increase vertical height is extremely conservative because the porcelain is lying on top of the exist- ing teeth. Even if the available biological width is significant, correcting the bite allows the dentist to remove less gum tissue during the gingivectomy. A frenectomy can also be performed, when appropriate, to remove a small portion of the lip frenulum with a diode laser. This allows the lip to move down slightly over the previ- Clinical COSMETIC TRIBUNE | March 20104C AD dimension can have dramatic cos- metic effects on a patient by increas- ing the crown-to-gum ratio and effectively decreasing the gummy smile. The cases presented here illus- trate that vertical abnormalities such as gummy smiles may sometimes be further enhanced and the need for surgical intervention minimized if the vertical dimension of the bite is altered. In adjusting the vertical dimen- sion, care must be taken to insure a functional occlusion in the fin- ished case. Jankelson described the method for muscle relaxation to determine mandibular position at true physiologic rest.5 Application of transcutaneous electrical nerve stimulation (TENS) (J5 Myomoni- tor*) for a period of 30–40 minutes allows the muscles of mastication innervated by cranial nerves 5 and 7 to relax. While there is no universal agree- ment among dentists on occlusal philosophy, the author has found the Jankelson method of establishing a true mandibular physiologic rest position (PRP) to be highly effective. PRP is objectively verified with sur- face electromyography and comput- erized jaw tracking (K7 Evaluation System). The K7 System provides calcula- tions that show when the patient is at physiological rest as compared to habitual rest. These calculations indicate how much vertical index g CT page 6C

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