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A case of dentofacial abnormality

6 February 2019

A case of dentofacial abnormality

Dentofacial abnormalities are alterations in facial proportion and dental relationships, and such abnormalities in dental and facial appearance often lead to societal discrimination. While orthodontic treatment restores correct dental relationships, it is often not sufficient to solve the facial disharmony and certainly cannot resolve the accompanying psychological difficulties in certain patients.

Aesthetic analysis
For this reason, aesthetic medicine is utilised to harmonise the final result. Owing to virtual dentistry, the expected smile and face of the patient at the end of orthodontic therapy and aesthetic treatment can be shown to the patient. In order to achieve this, a new diagnostic approach is used in the correction of dental malocclusion: capturing and analysing preoperative photographs in conjunction with CT scans and X-rays with the help of 3-D software specifically for aesthetic dentistry. In this way, the final expected result can be shown to the patient.

Often the patient is directed to a dental consultant because he or she does not like his or her smile and this has affected him or her psychologically such that aesthetic dentistry is inevitable.

The role of the dentist today should be to ensure that the reasons for intervention will be agreed upon with the patient and to ensure predictability of the aesthetic result.

Many dentofacial disharmonies are caused by malocclusion, classified according to Angle’s molar relationships (Fig 1b). The soft tissue of the vestibule and the lips lies over the dental hard tissue and is therefore influenced by the molar relationships.

Figure 1b

In examining the patient, we could consider, for example, his or her profile from the labial view. When a patient comes to my office for examination, in recording his or her medical history I pay much attention to preoperative photographs in seeking to determine the cause of aesthetic disharmony.

In the case presented here, three extra-oral photographs were taken from the front and three extra-oral photographs were taken from the side (Fig 2). Intra-oral examination found that the patient presented with a Class III/I malocclusion with a pronounced overjet. From the extra-oral photographs, the macroscopic incongruity in the labial relationship is evident because although the patient had her mouth closed and lips soft the lips are not touching. The face is asymmetrical in the inferior third and the smile line is not aligned with the occlusal plane, and is oblique and does not run parallel to the bipupillary line.

Figure 2

 3-D software in aesthetic dentofacial analysis

Today, we can design smiles more reliably and in a more sophisticated manner to correct the smile of our patients (smile makeover) using 2-D and 3-D dental software (Fig 3a). ClinCheck 3-D software (Align Technology) for use by dentists to create transparent orthodontic and dental aligners has proven to be an excellent tool in dentofacial aesthetic analysis, not only from an orthodontic perspective but also from an aesthetic perspective.

Figure 3a

In this case, orthodontic therapy using Invisalign (Align Technology) was proposed. Impressions taken of the dental arches, X-rays, photographs and diagnosis with a treatment plan were processed by  3-D, which allow the dentist to see and change all the therapeutic orthodontic steps necessary to align the teeth.

Biomechanical steps ensure greater predictability in orthodontic clinical cases for both the clinician and the patient. The initial phase of aligner movement and the final situation can be superimposed on a photograph of the face of the patient using 2-D software (Fig 3c). ClinCheck has among its options a millimetre grid that can be superimposed on the photograph and the steps shown according to conventional reference lines (Figs 4a–c). In this way, one can obtain a predictable dentofacial analysis from both a dentoskeletal perspective (alignment) and a dentolabial perspective (labial/perilabial repositioning).

Figure 3c Figure 4a Figure 4b Figure 4c

The analysis of the clinical case in question demonstrated a drastic closure overjet of about 3 mm as the final post-orthodontic treatment outcome (Fig 4d). Since the soft tissue of the lips and of the vestibule lie on the skeletal structures, it is possible to predict the future dentolabial relationship (Fig 4e). At this point, aesthetic predictability for the patient is important because at this stage the combined results of dentistry and aesthetic medicine are shown. In fact it is possible to simulate virtually the new labial dimension following aesthetic dental treatment and cosmetic labial or perilabial surgery.

Figure 4d Figure 4e

A 47-year-old female patient presented with malocclusion with crowded teeth in the maxilla and mandible and an incongruous dentolabial relationship. The clinical case was treated with 28 upper and 20 lower aligners, with interproximal reduction and attachments in both arches. The superior/inferior midline was moved during the process of sagittal correction (Fig 5a).

Figure 5a

In keeping with the protocol described above, and at the explicit request of the patient, it was decided to approach treatment in accordance with the dentofacial aesthetic analysis obtained using ClinCheck 3-D (Fig 5b). Using software to show the predicted movement on the grid allows the patient to see the expected changes (showing the lips with or without surgical remodelling; Figs 5c&d). The preoperative analysis can be verified at the end of therapy by superimposing all of the images available (Fig 6a).


Figure 5b Figure 5c Figure 5d Figure 6a

Once the dental treatment had been completed, we decided together with the patient to increase the lip volume using hyaluronic acid (Figs 6b&c). About two weeks after surgery, it was possible to verify what had been expected in the analytical aesthetic phase (Figs 7a–c&8).

Figure 6b Figure 6c


Figure 7a Figure 7b Figure 7c Figure 8


Combined aesthetic dentistry and aesthetic medicine can offer optimal and predictable treatment in the majority of clinical aesthetic cases. Using digital technology, the predicted outcome of such treatment for smile design can be shown to the increasing number of patients presenting for aesthetic treatment.

Editorial note: A complete list of references is available from the publisher.

Dr Valerio Bini, DDS in dentistry and dental prosthetics from the University of Genoa in Italy, is a cosmetic dentist. He is a member of the European Society of Cosmetic Dentistry, a fellow of SIED (Italian society of aesthetic dentistry), a fellow of the Italian Academy of Esthetic Dentistry, and Align Technology Invisalign certified. He regularly attends courses for specialist clinicians in aesthetic dentistry and aesthetic medicine. He has been a speaker at international conferences on aesthetic dentistry and aesthetic medicine. He is also the author of many articles published in international journals. 

This article was first published in the April 2014 issue of Dental Tribune UK


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