Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology

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1 JIOS Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering /jp-journals the Gull-Wing Lip Morphology Case Report Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology 1 Ashok Surana, 2 Siddhartha Dhar, 3 Abhisek Ghosh ABSTRACT The paradigm of orthodontics in the past century has been limited to the dentoalveolar segment and to some extent the jaws. The shift from hard tissue paradigm to soft-tissue has wide ned our focus on how we look at the face as a whole. Brin ging about changes in soft-tissue contours, once thought to be beyond the scope of orthodontics are now being addressed to. Once such example of atypical soft-tissue morphology is the gull-wing lip pattern. This pattern is identified by an obvious increase in incisal exposure at rest and smile and an excessive difference between the philtrum and commissural length. The lip morphology is known to be dependent on the vestibular sulcular depth which in turn depends on the vertical anterior teeth root positioning. The vertical incisal show is merely a manifestation of improper sulcular morphology seen in the gull-wing lip pattern. The true intrusion of maxillary incisors and simultaneous torque controlled retraction tends to alter the sulcular morphology and in turn the gull-wing pattern. Keywords: Gull-wing lip, Soft-tissue morphology, Torque controlled intrusion and retraction, Microimplant. How to cite this article: Surana A, Dhar S, Ghosh A. Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology. J Ind Orthod Soc 2014;48(4): Source of support: Nil Conflict of interest: None Received on: 21/8/13 Accepted after Revision: 10/10/13 INTRODUCTION If we say that eyes are the mirror of the soul and nose is the reflection of the character, mouth is for certain the reflection of sensuality. When we talk about facial esthetics, there are three main features that struggle for domination mouth, eyes and nose. Mouth being the center of communication 1 Professor and Head, 2 Reader, 3 Assistant Professor 1-3 Department of Orthodontics and Dentofacial Orthopedics Guru Nanak Institute of Dental Sciences and Research, Kolkata West Bengal, India Corresponding Author: Ashok Surana, Professor and Head Department of Orthodontics and Dentofacial Orthopedics, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India, Phone: , life_line_dental@ yahoo.co.in in the face, esthetic part of oral region is a conspicuous part of facial attractiveness. Assessment of the lips has always played an important role in the perception of facial beauty and the lip tooth relationships are the key to esthetic orthodontic treatment planning. Anthropological findings suggest that the contour and features of lips may vary from individual to individual. Abnormal morphology of lips can seriously compromise frontofacial esthetics. One such atypical lip morphology is the gull-wing lip pattern. CLINICAL FEATURE/CHARACTERISTICS GULL-WING LIP PATTERN Normally, the upper tubercle hangs slightly inferior to the vermillion on either side of it. However, in certain cases the tubercle may be superior to the adjacent vermillion or be entirely absent. This deformity is called the gull-wing upper lip. In this upper lip deformity, a short philtrum results in an unesthetic reverse resting lip line resembling a frown, which also resembles the wings of a seagull bird in flight (Fig. 1) and hence the name. Normally, the upper teeth are exposed beneath the upper lip up to 3 mm with the lips relaxed. Gull-wing lip deformity is clinically demonstrated by measuring the exposure of each tooth in relation to upper lip and the philtrum and commissural length (Fig. 1). The etiology of this lip-contour deformity lies along the vermilion border. At the lip junction of the frontonasal (premaxilla) and the maxillary process there is a deficiency of the mesoderm that results in paired furrows in the margins of the lip vermillion. This deformity is described as gullwing contour. Ideally in artistically beautiful lips 1-3 upper lip should pro trude out further than the lower lip. The width of phil trum at junction of vermillion is ideally 10 to 11 mm. The lower lips are like twin Faberge eggs, larger, fuller and volumetrically more than the upper lips. The lateral commissure lies at a vertical line drawn down from medial iris pupil. The upper lip has a slight but distinct white roll. 1 The horizontal line joining two commissures ideally sits on lower third point of the center of upper lip. The distinctive cupid s bow has a slight upward tilt from the commissure to the cupid s peak of 10 to 20. The distance from the base of columella to the cupid s bow is equal or shorter than the distance from the The Journal of Indian Orthodontic Society, October-December 2014;48(4):

2 Ashok Surana et al Fig. 1: Assessment of gull-wing lip morphology lower lid lash to the supratarsal crease. The upper lip length measured from subnasale to upper lip inferior is usually 19 to 22 mm. The lower lip length from lower lip superior to soft-tissue menton is 38 to 44 mm. The ratio between upper and lower lip length is 1: Youthful resting upper lip has a soft M or lazy M shape to the upper vermillion border. 4,7 There is a parallel shape of the lip embrasure between upper and lower lips. The upper vermillion length (6-9 mm) is usually 2 to 3 mm less than the lower vermillion length (8-12 mm). With lips at rest the upper incisor exposure measured from upper lip inferior to upper incisal edge is usually 1 to 5 mm. Facial rejuvenation is best at 3 to 5 mm of exposure and females show more in this range. 4,8 On smiling the ideal exposure with smile is 3 quarter of crown height to 2 mm of gingival exposure. With balanced lip and skeletal lengths, the lips should ideally close from a relaxed separated position without lip, mentalis or alar base strain. 4,8 There is a definite relationship between philtrum and commissure with respect to age. Maxillary display of incisors and maximum lip incompetence occurs at 11 years of age for girls and 12 years of age for boys. Philtrum height trails behind the vertical height of the lower face in childhood and catches up during and after adolescence. This height increases during adolescent growth spurt at a faster rate than commissure height. This explains the phenomenon of lip incompetence in young individuals. 9 The correlation coefficient between philtrum: commissure height is The degree of lip separation at rest equals the difference between commissure and philtrum height. 4,9 In adolescence, philtrum height is often shorter than the commissure height and the difference is due to the differential in lip growth with maturation. The absolute linear measurement of philtrum is not important but its relationship to the upper incisor and commissure of the mouth is significant. 9 Lip growth can also affect vertical incisal exposure. It is usually completed at a younger age in girls (14 years for upper lip, 16 years for lower lip). In boys, the lips continue to grow vertically into the late teens. 4,8 However, as age progresses there are a gradual alteration in the morphology of the lips. It is characterized by, flattening of M shape, lips becoming thinner, diminished turgor of lips, drooping of commissures and lengthening of philtrum and commissure. All these result in reduction in tooth display at rest and reduction in gingival display on smile. 3 Incisor display is also different at different age groups and differs among sexes. Compared to males, females exhibit more maxillary and less mandibular incisor display. Maxillary incisor display at rest are 15 years of age 4.7 mm (boys), 5.3 mm (girls), 20 to 30 years of age 3 mm, 30 to 40 years of age 1.5 mm, 40 to 50 years of age about 1 mm, 50 to 60 years of age no display normally. 4,8 DIAGNOSIS OF Gull-wing LIP MORPHOLOGY When the distance between philtrum height and commissure height is 10 mm or more, it marks the establishment of gullwing lip deformity (Fig. 1). The differential diagnosis would involve: at rest vertical maxillary excess, dentoalveolar protrusion. On smile vertical maxillary excess, short clinical crown, large lip elevation on smile, upright incisors. TREATMENT PROTOCOL FOR Gull-wing LIP MORPHOLOGY 10,11 Since the lip morphology is directly related to the morphology of the vestibular sulci, the answer to the correction of gullwing lip morphology is to produce torque controlled true intrusion and retraction of incisors. Since its biomechanically difficult to produce true intrusion and retraction with regular orthodontic mechanics, rigid microimplant-supported anchorage with two in the anterior dentoalveolar segment and two 336

3 JIOS Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology A B C Figs 2A to C: Intrusion-retraction mechanics: (A) Right lateral view, (B) frontal view and (C) left lateral view in the posteriors are used to intrude and retract the incisors simultaneously It has been documented in literature 5 that, for every 1 mm of retraction, there is 0.5 mm reduction in the interlabial gap, when retraction is not associated with either intrusion or extrusion of incisors. When retraction is associated with intrusion of incisors, every 1 mm of retraction reduces the interlabial gap by 1 mm (i.e. proportionately). When retraction is associated with extrusion of incisors, 1 mm of retraction does not reduce the interlabial gap. Thereby simultaneous intrusion and retraction of incisors has been seen to alter the vertical root positioning, which in turn alter the sulcular morphology and thereby correct the gull-wing lip pattern (Figs 2A to C). 5,13,14 Case Reports Case 1 Patient presented with a Class I bimaxillary protrusion, a convex profile, and lip incompetency of 9 mm with full length incisal exposure. She also had a vertical growth pattern. To add to that she had a gull-wing lip morphology with commissural length to philtrum length difference of 12 mm (Figs 3A to G). Cephalometric parameters confirmed the clinical findings, suggesting proclined upper and lower incisors and a vertical growth pattern. The upper incisal edge to NF measurement suggested an increased anterior dental height (Table 1 and Figs 3H and I). The treatment objective was to attain normal inclination of upper and lower incisors, to attain normal overjet and overbite with a Class I canine and molar relationship, to correct the convexity of the profile, to attain lip competency and finally to correct the gull-wing lip pattern. The treatment involved the extraction of four 1st premolars followed by the initial leveling and alignment of arches with 0.014", 0.016" Nitinol wires and then by rigid wires (0.018" ss and 0.019" 0.025" Niti). The intrusion and retraction mechanics was started on 0.019" 0.025" ss wire with inverted soldered hook placed just distal to the lateral incisor bracket. Simultaneous true intrusion and retraction was done using power chains attached from microimplants placed distal to lateral incisors and 2nd premolars bilaterally. The case was finished in a good Class I molar and canine relationship with normal overjet and overbite. The convexity of the profile reduced grossly, competency of the lips was established and the gull-wing lip pattern was corrected. The philtrum to commissural length difference reduced by 4 mm post-treatment. Standard retention protocol with Hawley s appliance and bonded lingual A B C D Figs 3A to D: Extraoral pretreatment photographs: (A to C) Pretreatment frontal and lateral extraoral views and (D) assessment of gull-wing lip morphology (patient 1) The Journal of Indian Orthodontic Society, October-December 2014;48(4):

4 Ashok Surana et al E F G Figs 3E to G: Intraoral pretreatment photographs right lateral, frontal and left lateral views H I Figs 3H and I: Pretreatment lateral cephalogram and orthopantomogram J K L M Figs 3J to M: Extraoral post-treatment photographs (J to L) and (M) assessment of corrected gull-wing morphology N O P 338 Figs 3N to P: Post-treatment intraorals right lateral, frontal and left lateral views

5 JIOS Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology Table 1: Pre- and post-treatment comparison (patient 1) Parameters Pretreatment Post-treatment ANB 5 2 FMA Sn-Go-Gn Upper 1-NA 41 /11 mm 30 /7 mm Lower 1-NB 37 /11 mm 27 /5 mm Interincisal angle Upper incisal tip-nf 28 mm 23 mm Nasolabial angle Lower lip to E-line 3 mm 2 mm retainers in both upper and lower arch was followed. Patient was advised to use Tooth Mousse to overcome the mild white spot lesions that developed in the molar region due to improper oral hygiene during the treatment period (Figs 3J to P). Cephalometric comparisons revealed true intrusion (upper incisor to NF values reducing by 5 mm) and retraction of upper incisors, with significant changes in vertical and horizontal parameters (both skeletal and dental) (Table 1 and Figs 3Q to S). Case 2 Patient presented with a Class II Div 1 malocclusion, a convex profile, lip incompetency of 10 mm with full length incisal exposure and a gummy smile. The patient had a vertical growth pattern. She also had a gull-wing lip morphology with commissural length to philtrum length difference of 14 mm (Figs 4A to G). Cephalometric analysis suggested proclined upper and lower incisors and a vertical growth pattern. The upper incisal edge to NF measurement of 30 mm suggested an increased anterior dental height (Table 2 and Figs 4H and I). The treatment objective was to attain ideal inclinations of upper and lower incisors, to attain normal overjet and overbite with a Class I canine and molar relationship, to correct the convexity of the profile, to attain lip competency, to correct the gull-wing lip pattern and the gummy smile. The treatment involved the extraction of three 1st premolars and lower right side 2nd premolar (to correct the molar relationship to Class I). This was followed by the initial leveling and alignment of arches with 0.014", 0.016" Nitinol, 0.018" ss and 0.019" 0.025" Niti). The intrusion and retraction mechanics was initiated on 0.019" 0.025" SS wire with inverted soldered hook placed just distal to the lateral incisor bracket. Simultaneous true intrusion and retraction was done using power chains attached from microimplants placed distal to lateral incisors and 2nd premolars bilaterally. Q R S Figs 3Q to S: Post-treatment lateral cephalogram, orthopantomogram and superimposition The Journal of Indian Orthodontic Society, October-December 2014;48(4):

6 Ashok Surana et al A B C D Figs 4A to D: Extraoral pretreatment photographs (A to C) Pretreatment frontal and lateral extraoral views and (D) assessment of gull-wing lip morphology (patient 2) E F G Figs 4E to G: Intraoral pretreatment photographs: Right lateral, frontal and left lateral views H I Figs 4H and I: Pretreatment lateral cephalogram and orthopantomogram J K L M 340 Figs 4J to M: Extraoral post-treatment photographs: (J to L) Post-treatment frontal and lateral extraoral views and (M) assessment of corrected gull-wing morphology

7 JIOS Torque Controlled True Intrusion and Retraction: A Novel Protocol for Altering the Gull-Wing Lip Morphology N O P Figs 4N to P: Post-treatment intraorals: Right lateral, frontal and left lateral views Q R S Figs 4Q to S: Post-finishing lateral cephalogram, orthopantomogram, superimposition The case was finished in a class I molar and canine relationship with normal overjet and overbite and coinciding facial and dental midlines. The convexity of the profile reduced significantly, competency of the lips was established and the gull-wing lip pattern corrected. The commissural length to philtrum length difference reduced by 5 mm post-treatment. Standard retention protocol with Hawley s appliance and bonded lingual retainers in both upper and lower arch was followed (Figs 4J to P). Cephalometric comparisons revealed true intrusion and retraction of upper incisors (Upper incisor to NF reducing by 5 mm). The vertical discrepancies were addressed to and almost normal inclinations of upper and lower incisors were attained (Figs 4Q to S and Table 2). Table 2: Pre- and post-treatment comparison (patient 2) Parameters Pretreatment Post-treatment ANB 7 4 FMA Sn-Go-Gn Upper 1-NA 35 /11 mm 14 /4 mm Lower 1-NB 34 /9 mm 30 /7 mm Interincisal angle Upper incisal tip-nf 30 mm 25 mm Nasolabial angle Lower lip to E-line 3 mm 2 mm REFERENCES 1. Kaplan EN. The occult submucous cleft palate. Cleft Palate J 1975 Oct;12(4): Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning: Part I. Am J Orthod Dentofacial Orthop 1993;103(4): The Journal of Indian Orthodontic Society, October-December 2014;48(4):

8 Ashok Surana et al 3. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning: Part II. Am J Orthod Dentofacial Orthop 1993;103(5): Dickens ST, Sarver DM, Proffit WR. Changes in the frontal soft tissue dimension of the lower face by age and gender. WJO 2002;3(4): Jacobs JD. Vertical lip changes from maxillary incisor retraction. Am J Orthod 1978 Oct;74(4): Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning: Part I. Am J Orthod Dentofacial Orthop 1983;84(1): Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod Dentofacial Orthop 1984;85(4): Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part I. Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop 2003;124(1): Mamandras. Linear changes in maxillary and mandibular lips. Am J Orthod Dentofacial Orthop 1988;94(5): Burrow JS. Biomechanics and the paradigm shift in orthodontic treatment planning. J Clin Orthod Polat-Ozsoy O, Arman-Ozcirpici A, Veziroglu F. Miniscrews for upper incisor intrusion. Eur J Orthod 2009 Aug;31(4): Talass MF, Baker RC. Soft tissue profile changes resulting from retraction of maxillary incisors. Am J Orthod Dentofacial Orthop 1987;91(5): Park YC, Burstone CJ. Soft-tissue profile fallacies of hard tissue standards in treatment planning. Am J Orthod Dentofacial Orthop 1986;90(1): Jacobson A. Planning for orthognathic surgery art or science? Int J Adult Orthod Ortho Surg 1990;5(4):

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