acific Coast Society of Orthodontists Bulletin Summer 2018 - 56

Presentation Summary

may be posterior tooth wear and fractures, even
with anterior tooth wear. There can also be an
avoidance posture in rest, speaking, and swallowing. Observation of faces with lip incompetence
reveals upper lip closure with narrowing of the
ala of the nose, greater nostril display, deep
nasolabial folds, and elongated upper lip. Mentalis closure can result in chin ptosis.
There have been no research studies with interlabial gap as the variable, but many studies have
shown an association between TMJ dysfunction
and skeletal Class II with longer faces. In comparison to oral breathing patterns, nasal breathing
has a lower level of upper airway resistance and a
lower risk for apnea. Mouth breathing leads to
musculoskeletal impairment by altering respiratory function and mechanics; it produces postural compensations, in turn perpetuating the
respiratory changes. Lower muscle strength and
exercise capacity may follow, with a negative
effect on the patient's quality of life. The individual may have difficulty in opening fully, and there
can be pain over the body and angles of the
lower jaw.
Clinical Recommendations
Measure the interlabial gap with joints seated, at
the first tooth contact, with lips relaxed. The distance between the stomion superius (Ss) and the
stomion inferius (Si) should be 0 to 2 mm. In
treating the excessive interlabial gap, the determinants include lip length, vermillion, upper incisor crown height, upper incisor exposure, overbite,
lower incisor crown height, and lower incisor
exposure. Snı (base of the nose) to Ss should be
18 to 20 mm, and Si to soft tissue menton (Meı)
should be 40 to 42 mm. Assess the shape of the
vermillion of the lips through thickness and
tubercle/lobes. If there is a lip length problem, it
can be treated with a lip lift. If there are issues
with the shape of the vermillion, fillers can be
considered.

56

Measure the crown heights of the unworn maxillary central incisor, for which 11.5 to 12 mm is the
norm. Correct lip length and incisor lengths give
meaning to incisor exposure and overbite. Measure the upper incisor exposure by first checking
tooth position. Is it hypereruption (check gingival
margins and check for black triangles)? If not,
then check the amount of exposure, which averages 2 to 4 mm (but review with the patient to
see if that is esthetically acceptable). Establish
the functionally esthetic edge (FEE) line by deciding where the maxillary central incisor should
be, and set the canine level on the same plane.
Measure the maxillary occlusal plane and determine if and how it needs to change. The FEE line
will then dictate treatment for the incisor, such
as by orthodontic intrusion, orthognathic surgery, or restoration.
How much overbite is enough? Three to 4 mm
protects the joints and is more esthetic. Anterior
open bites can be closed through posterior subtractive coronoplasty, posterior intrusion, anterior
additive coronoplasty, anterior extrusion, or surgery. Measure the lower incisor exposure. It is not
supposed to be visible at rest, because with normal lip lengths and chin length there is an average upper incisor exposure of 3 mm at rest and
an overbite of 3 mm with lips touching. Remember that there can be hypereruption of lower incisors which tends to reduce an existing open bite.
This needs to be removed by decompensating to
a greater open bite presurgically.
The four functional facial keys of respiration,
mastication, perception, and communication
should guide our diagnosis and treatment planning. Avoid making patients longer in the front
when the lips cannot get together. They will continue to have problems, and it won't be esthetic.
Remember, the lips must be able to touch without effort. 

PCSO Bulletin  Summer 2018



Table of Contents for the Digital Edition of acific Coast Society of Orthodontists Bulletin Summer 2018

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