October 13, 2025 • 16 mins
Presents an interdisciplinary framework for dental diagnosis and treatment planning, emphasizing a "Global Diagnosis" system based on Five CORE Questions to evaluate facial proportions and tooth position, contrasting it with traditional "regional" approaches. Key topics addressed include specific treatment modalities such as esthetic crown lengthening surgery, tissue grafting, orthodontic intrusion and forced eruption, orthognathic surgery, and dental facial plastics (Botox and dermal fillers). The sources also detail the Global Analysis Diagnosis (GAD) form for systematic data collection and discuss the critical importance of sequencing various specialty treatments—periodontal, orthodontic, and surgical—to achieve optimal esthetic and functional outcomes for complex adult patients.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the deep dive. This is where we take
a complex stack of sources and well give you the
ultimate shortcut to being truly.
Speaker 2 (00:08):
Well informed, cutting through the noise.
Speaker 1 (00:10):
Exactly today we're diving deep into a blueprint for systematic,
comprehensive dental treatment planning. We're focusing on the really game
changing principles from Global Diagnosis, a new vision of dental
diagnosis and treatment planning by Robinson Rous.
Speaker 2 (00:28):
It's a foundational text for this approach.
Speaker 1 (00:30):
Absolutely so if you're a young professional, maybe a student,
or you know, just trying to navigate complex restorative cases,
this deep dive, well it might just fundamentally change how
you approach planning these things.
Speaker 2 (00:42):
It shift the whole perspective right.
Speaker 1 (00:43):
The core mission here, as I understand it is to
get past that feeling of being overwhelmed by information. So
instead of diagnosing just isolated tooth issues what they call
the regional diagnosis trap, we aim to establish a unifying
global diagnosis. We're figuring out the ideal position of the
teeth and gums not just for function, but critically within
(01:04):
the patient's whole facial frame. It's bigger picture and.
Speaker 2 (01:07):
What's really powerful about this method I think is it's
laser focus on finding the root cause the ethiology. You know,
why is the gingiva where it is? Is there a
skeletal issue? Once you determine that underlying reason, well, the
treatment options really narrow down fast.
Speaker 1 (01:23):
Ah.
Speaker 2 (01:24):
Okay, the path forward becomes honestly, strikingly clear. The diagnosis
doesn't just like inform the treatment plan, it practically dictates it.
Speaker 1 (01:33):
Okay, let's unpack that shift then, Because historically dentistry often
felt it well, like you said, drowning in data, right,
no clear map. Traditional diagnosis was so heavily driven by occlusion,
TMJ checks, mounted casts, charting just endless lists of regional problems.
Speaker 2 (01:50):
Yeah, endless.
Speaker 1 (01:51):
Why did having all that regional data leave so many
dentists feelings stuck, like they didn't know where to start?
Speaker 2 (01:56):
Well, because data overload isn't the same as having a diagnosis,
is it right? You generate I don't know, dozens of
these small regional diagnoses the pulp status here, or pocket
depth there, wear facets, but there was no unifying structure,
nothing told you where to actually begin the reconstruction. The
sequence was often just broken.
Speaker 1 (02:11):
Treating the trees, not seeing the forest.
Speaker 2 (02:14):
You got it you were treating individual trees when you
needed a map of the whole forest.
Speaker 1 (02:18):
It's interesting you say that if you compare it to
general medicine. Right, a patient comes in main complaint, doctors
move pretty quick to a global diagnosis, you know, like cancer,
staging or something, and that diagnosis drives the main treatment protocol.
Regional stuff like hypertension, it just modifies the plan. It
doesn't drive the whole strategy precisely.
Speaker 2 (02:39):
And in dentistry, look that regional approach. It used to
be okay because frankly, our tools were more limited. But
things started changing back in the early eighties. The focus
shifted towards what they called facially generated diagnosis, okay, prioritizing
tooth position aesthetics. The belief was function would kind of follow,
and they really zeroed on the position of the incisile edges.
Speaker 1 (03:02):
But even that approach, the one focus just on the
incisile edges, it had a pretty major flaw, didn't it.
Speaker 2 (03:06):
Oh, absolutely, you could get.
Speaker 1 (03:07):
Those biting edges perfectly lined up, step back and realize
the whole smile was still well an aesthetic mess. Why
was the gingeeba the missing piece there?
Speaker 2 (03:17):
Because the incisile edge position. It's only half the story.
It's just not enough. The global diagnosis system forces you
to recognize that if the gingevile tissues and the overall
smile frame are unacceptable, think uneven gum levels or that
really excessive gingevil display the gummy smile, then the whole
result is basically an esthetic failure. No matter how perfect
(03:39):
the incisile edges are, you have to figure out the
why behind the gingevile problem first.
Speaker 1 (03:45):
So to structure that investigation to find the why, the
sources lay out this tool, the Global Analysis Diagnosis Form
or gad form. It sounds efficient, maybe five minutes to
fill out, but it clicks really specific essential information. It's
pure efficience, honestly, and it organizes things from the outside
in face first, then teeth exactly.
Speaker 2 (04:04):
It directs your focus immediately to the measurements that actually
establish that global diagnosis. Let's maybe focus on five critical
ones from the sources, starting with face height.
Speaker 1 (04:13):
Okay, face height rule of thirds yep.
Speaker 2 (04:15):
Using the classic rule of thirds to check vertical facial proportions.
Speaker 1 (04:19):
So how are we measuring this? What are we looking
for specifically?
Speaker 2 (04:22):
Okay? So you measured the middle third that's from the
globella between the eyebrows down to the subnasal where the
nose meets the upper lip. Got it, And you compare
that length to the lower third, which runs from the
subnasal down to the mint and the tip of the chin.
And crucially this is important, measure it with the patient
and repose lips totally relaxed, not smiling, no, definitely not smiling.
(04:45):
If that lower third measurement is significantly longer than the
middle third, that's a big red flag for a potential
vertical maxillary excess.
Speaker 1 (04:53):
V Amy okay, skeletal discrepancy makes sense. Moving inward. Then
the second metric is lip length and mobility. We need
numbers here, right we do.
Speaker 2 (05:02):
The sources give averages. For a young woman, upper lip
length is typically around twenty to twenty two millimeters, men
usually a millimeters or two longer.
Speaker 1 (05:10):
And mobility.
Speaker 2 (05:11):
Mobility is how far that lip travels from repose to
a full maximum smile. Normal is about six to eight millimeters.
Speaker 1 (05:17):
And getting that full smile is key, I imagine.
Speaker 2 (05:20):
Absolutely critical for diagnosis. You might need to get the
patient to actually laugh genuinely or use tricks like the
high E rule. Having them say eee, to really stretch
the lip up, you need to see the maximum movement.
Speaker 1 (05:32):
Okay. Third, we look at the central incisor exposed and
repose our baseline reference.
Speaker 2 (05:38):
Yes, and this is a huge diagnostic clue. A young
woman on average shows about plus three to plus four
millimeters of a central incisor when.
Speaker 1 (05:46):
Her lips are relaxed, and a young man.
Speaker 2 (05:48):
Typically plus one to plus two millimeters. And this also
helps us understand aging effects. You know how so well,
the upper lip tends to lengthen by about one millimeters
per decade after age forty, so you see less incisile
display as people get older.
Speaker 1 (06:02):
At all connects interesting fourth metric the dental facial mid
line right.
Speaker 2 (06:07):
Ideally this should be perpendicular to the horizon, lined up
with a facial mid line off and running through the
little dip in the upper lip, the cube its bow tip.
Speaker 1 (06:14):
How much wiggle room is there?
Speaker 2 (06:16):
Well, a small deviation, say less than two millimeters off
the facial mid line often acceptable. Most people won't notice it. However,
the authors are really clear on this. A can't meaning
the whole mid line is tilted relative to the horizon.
That's visually unappealing. To pretty much everyone dental pro or
not that needs correction.
Speaker 1 (06:34):
Okay, a cant is a definite problem. And finally number five,
this sets up the gingible diagnosis. Checking the CEJ location
the cemento enamel junction.
Speaker 2 (06:44):
This is absolutely fundamental in a healthy situation where the
anatomical crown is fully exposed. You should be able to
gently feel that distinct texture Chaine smooth enamel to rougher
cementum right at the CEJ when you probe the sulcus.
Speaker 1 (06:57):
And its position relative to the bone.
Speaker 2 (06:59):
That's the key anatomical marker in health. The CEJ should
set about two millimeters coronal, meaning above the crest of
the alveolar bone. Remembering that specific two milimeter relationship is
what confirms diagnoses like ape later on.
Speaker 1 (07:12):
Okay, So that detailed data from the giadoosan form. It
acts like a funnel guiding us into these five core questions.
These questions, they're really the heart of the system, aren't they.
They force you to use those measurements to land on
a definitive global diagnosis and from there the treatment plan.
Speaker 2 (07:29):
Exactly they translate the numbers into a diagnosis. Let's walk
through them. Please, Question one what are the facial proportions
and skeletal relationships? So, if that GD data showed the
lower third was significantly longer than the middle third, EM
diagnosis vertical maxillary excess VME means the maxilla grew too
much vertically. Since it's a skeletal problem, the definitive primary
(07:51):
treatment is surgical a maxillary la fort on maction orthognatic
surgery to physically move the maxilla up makes sense.
Speaker 1 (07:59):
Question two, what are the length and mobility of the
upper lip? So if filip is short, or if it
moves more than that normal eight millimeters, creating that gummy smile.
Speaker 2 (08:07):
Then the diagnosis is either short upper lip or hyperactive
upper lip.
Speaker 1 (08:10):
And the primary treatment here less invasive usually.
Speaker 2 (08:13):
Yeah, because these are soft tissue issues, or perhaps muscle
activity issues. For hyperactive lip, maybe botox injections to calm
down the muscle movement. For a genuinely short lip, you
might consider dermal lip fillers to add a bit of
vertical length. At rest, behavior modification techniques are sometimes mentioned too, that.
Speaker 1 (08:30):
These are masking if the real issue is VME.
Speaker 2 (08:33):
Absolutely, if the underlying cause is skeletal VME and the
patient decline surgery these are just camouflage options. Important distinction.
Speaker 1 (08:40):
Got it? Question three? What is the relationship between the
gingible line and the horizon? What if that line looks
scooped out like concave or it's canted tilted.
Speaker 2 (08:51):
That pattern suggests the teeth and the bone supporting them,
the dental of the older complex have actually super erupted
or over erupted.
Speaker 1 (08:58):
Downwards, leading to the diagnosed.
Speaker 2 (09:00):
Dental O the older extrusion or GAE. And for this
the authors strongly strongly recommend orthodonic intrusion as the primary.
Speaker 1 (09:07):
Treatment, not surgery.
Speaker 2 (09:09):
They argue against functional crown lengthening surgery in this specific
DEAE scenario, mainly due to potential negative consequences we can
touch on later. Ortho intrusion is preferred, okay.
Speaker 1 (09:19):
Question four, what is the length of the maxillary central
incisor if it's noticeably short the book says less than say,
ten to eleven millimeters.
Speaker 2 (09:28):
Then you start thinking about one or three main causes microdoncha,
just genetically small teeth, attrition, wear and tear, or altered
passive eruption APE and question five is the decider right?
Speaker 1 (09:39):
Question five is the CEJ palpable in the gingevil sulcus.
So if the tooth is short and you probe that
sulcus and cannot feel the CEJ.
Speaker 2 (09:48):
BINGO, that confirms the diagnosis of altered passive eruption APE.
It means the gum tissue in the bone underneath fail
to migrate apically to the correct position during tooth eruption,
leaving part of the anatomical crown still covered up.
Speaker 1 (10:00):
Wow. Okay, so that's the power. The gad form takes
what might seem like just a gummy smile or a
short teeth complaint and gives you a highly specific singular
diagnosis like APE or DAE, and then the system pretty
much eliminates the guestwork by telling you the exact tool,
the exact interdisciplinary approach needed. Let's look at APE. How
that diagnosis points directly to esthetic crown lengthening surgery.
Speaker 2 (10:22):
Right, Esthetic crown lengthening surgery is indicated only for APE.
Its sole purpose is aesthetic to uncover the correct amount
of anatomical crown, getting the gingerble margin back to its
biologically intended level relative to the CEJA, and the sources
are incredibly precise about the surgical goals. There are three. First,
you thin the bone and move its crest to be
exactly two millimeters apical to the ceja.
Speaker 1 (10:44):
Okay, two millimeters below the ceja.
Speaker 2 (10:46):
Second, you position the new gingeral crust three millimeters coronal
to that new bone crest. That establishes the biologic width.
And third, obviously you level the tissue across the teeth
involved for a harmonious look.
Speaker 1 (10:58):
That precision is key, and it makes clear that this
ape surgery is totally different from functional crown lengthening, right.
Speaker 2 (11:04):
Completely different purpose and technique. Functional crown lengthening is purely
for biomechanical reasons. Maybe you need more tooth structure for
a crown to grab onto the feral effect. Or you're
treating a fracture that goes below the gum line. It
often involves different flap designs, maybe moving the gum tissue
apically onto the root surface, exposing cementum. Things you would
(11:25):
never do if your only goal was improving esthetics in
an ape case.
Speaker 1 (11:28):
Okay, crucial distinction. Let's swing back to dental aveular extrusion DAE,
the diagnosis where teeth have overrupted, you said, The authors
strongly prefer orthodontic intrusion over surgery why the strong stance
against surgery here.
Speaker 2 (11:43):
Well, think about it. If you try to do functional
crown lengthening on a tooth that has dae, meaning the
tooth and the bone around it have erupted too far down,
you're forced to remove a lot of bone and gum
tissue just to get the gum line back up. You're
not just uncovering the normal anatomical crown like an ape,
essentially cutting away tissue and bone from an already normally positioned, potentially.
Speaker 1 (12:04):
Long root surface, leading to problems.
Speaker 2 (12:06):
Yeah, big problems. You dramatically worsen the crowned root ratio,
making the tooth potentially less stable, and esthetically you often
end up with those really long, triangular looking restorations with
black triangles and unstable gum margins. It's generally not a
good outcome.
Speaker 1 (12:22):
So the orthodonic solution aims for absolute intrusion. What does
that mean exactly?
Speaker 2 (12:27):
It means moving the entire complex the tooth, the bone
around it, the attached gingiva bodily upward back along its
long axis. You're restoring the proper amount of tooth display
and leveling the gingevile line relative to the horizon, but
without surgically removing tissue.
Speaker 1 (12:43):
How do they control that movement so precisely?
Speaker 2 (12:46):
Often with temporary anchorage devices or tads, little mini implants
placed temporarily in the bone. They provide a stable, unmoving
anchor point to pull against, which allows for that controlled,
predictable absolute intrusion of teeth or segments, rather than just
tipping them, which is relative intrusion.
Speaker 1 (13:03):
Okay, that makes sense. Now let's flip the script entirely.
What about the opposite problem, not short teeth or gummy smiles,
but treating long teeth due to gingible recession.
Speaker 2 (13:12):
For recession, the key guide for predictability is the Miller classification.
Speaker 1 (13:16):
You need to know it remind us.
Speaker 2 (13:18):
Classes I in two generally mean you can expect complete
root coverage with grafting, usually a connective tissue graft. Class
three suggests only partial coverage is likely, and class four
basically means no root coverage is predictably achievable with grafting alone.
So the treatment decision, whether it's just restoration, grafting, or
maybe both, depends on assessing five things where the recession is,
(13:42):
how thick the gum tissue is, how deep the recession
defect is how much root is exposed, and importantly that
Miller classification.
Speaker 1 (13:49):
Okay, very systematic. Again, lastly, let's talk sequencing. Complex cases
often need multiple specialists. If a patient has ape needing
surgery and they also need ortho and restorations at afterwards,
how does this system dictate the timing.
Speaker 2 (14:03):
Timing is absolutely critical for the best outcome. The guideline
is that the esthetic crown lengthening surgery to correct the
ape should ideally happen about six months before the orthodonist
plans to remove the braces or appliances.
Speaker 1 (14:14):
Six months prior.
Speaker 2 (14:15):
Why then, because doing the surgery first levels the gingeeva,
establishing the correct final gum heights. This gives the orthodonist
a clear target. They can then move the teeth precisely
into their final apicocronal positions relative to that ideal gingeble line.
It completely removes the guesswork later on for the restorative
dentist when they're trying to figure out the final ideal
(14:38):
height to width ratios for veneers or crowns. Everything lines
up predictably.
Speaker 1 (14:42):
This system really does seem to demystify these complex interdisciplinary cases.
Speaker 2 (14:47):
It does.
Speaker 1 (14:47):
It forces you the clinician to stop just looking at
individual teeth and instead diagnose that root etiology, the why
behind the gingevile position. First, it provides that structured roadmap
for systemmadic care.
Speaker 2 (15:00):
You never start treatment until you know the destination.
Speaker 1 (15:03):
Exactly ensure as you know where you're going.
Speaker 2 (15:05):
And it's worth remembering too that while the core diagnoses
often point towards surgery or orthodontics, the system doesn't ignore
non surgical management when appropriate. For instance, you might diagnose
definitive VME, but the patient absolutely refuses orthognetic surgery. The
system acknowledges you can still use tools like botox and
dermal fillers dental facial plastics as pretty effective masking procedures
(15:29):
to reduce the gingible display and improve esthetics even if
you aren't correcting the underlying skeleton.
Speaker 1 (15:34):
It really highlights how interconnected all these facial esthetic elements are. Bone, muscle,
soft tissue, teeth. All right, To wrap this up, let's
leave our listeners with a quick thought exercise something that
pulls directly from that five core question structure we discussed.
Speaker 2 (15:49):
Good idea.
Speaker 1 (15:50):
Okay, imagine this, A twenty five year old female patient
comes into your office. Her chief complaint might be short teeth.
You measure her maxillary central in size and they are
indeed short, only eight millimeters long, well blow average. Now,
during your clinical exam, you gently probe the gingible sulcus
around those centrals with an explorer, but you cannot feel
(16:12):
that distinct, slightly rough transition of the cemento enamel junction.
It feels smooth all the way down.
Speaker 2 (16:18):
Okay.
Speaker 1 (16:19):
So, based on those specific data points, short clinical crown,
non palpable CEJ in the sulcus, and thinking back to
the five core questions, what is the most likely global
diagnosis here and what is the indicated primary treatment?
Speaker 2 (16:31):
Yeah, think about that crucial link short crown plus absence
of the CEJ feeling in the sulcus, what developed metal
process likely went wrong, and what specific surgical procedure is
designed only for that exact anatomical situation.
Speaker 1 (16:44):
Mull that over. Think about the system, the structure, the etiology.
It forces you to find. That really is the power
of global diagnosing.
Speaker 2 (16:50):
It brings clarity, it really does.
Speaker 1 (16:52):
We'll catch you next time for another deep dive.
Welcome to the deep dive. This is where we take
a complex stack of sources and well give you the
ultimate shortcut to being truly.
Speaker 2 (00:08):
Well informed, cutting through the noise.
Speaker 1 (00:10):
Exactly today we're diving deep into a blueprint for systematic,
comprehensive dental treatment planning. We're focusing on the really game
changing principles from Global Diagnosis, a new vision of dental
diagnosis and treatment planning by Robinson Rous.
Speaker 2 (00:28):
It's a foundational text for this approach.
Speaker 1 (00:30):
Absolutely so if you're a young professional, maybe a student,
or you know, just trying to navigate complex restorative cases,
this deep dive, well it might just fundamentally change how
you approach planning these things.
Speaker 2 (00:42):
It shift the whole perspective right.
Speaker 1 (00:43):
The core mission here, as I understand it is to
get past that feeling of being overwhelmed by information. So
instead of diagnosing just isolated tooth issues what they call
the regional diagnosis trap, we aim to establish a unifying
global diagnosis. We're figuring out the ideal position of the
teeth and gums not just for function, but critically within
(01:04):
the patient's whole facial frame. It's bigger picture and.
Speaker 2 (01:07):
What's really powerful about this method I think is it's
laser focus on finding the root cause the ethiology. You know,
why is the gingiva where it is? Is there a
skeletal issue? Once you determine that underlying reason, well, the
treatment options really narrow down fast.
Speaker 1 (01:23):
Ah.
Speaker 2 (01:24):
Okay, the path forward becomes honestly, strikingly clear. The diagnosis
doesn't just like inform the treatment plan, it practically dictates it.
Speaker 1 (01:33):
Okay, let's unpack that shift then, Because historically dentistry often
felt it well, like you said, drowning in data, right,
no clear map. Traditional diagnosis was so heavily driven by occlusion,
TMJ checks, mounted casts, charting just endless lists of regional problems.
Speaker 2 (01:50):
Yeah, endless.
Speaker 1 (01:51):
Why did having all that regional data leave so many
dentists feelings stuck, like they didn't know where to start?
Speaker 2 (01:56):
Well, because data overload isn't the same as having a diagnosis,
is it right? You generate I don't know, dozens of
these small regional diagnoses the pulp status here, or pocket
depth there, wear facets, but there was no unifying structure,
nothing told you where to actually begin the reconstruction. The
sequence was often just broken.
Speaker 1 (02:11):
Treating the trees, not seeing the forest.
Speaker 2 (02:14):
You got it you were treating individual trees when you
needed a map of the whole forest.
Speaker 1 (02:18):
It's interesting you say that if you compare it to
general medicine. Right, a patient comes in main complaint, doctors
move pretty quick to a global diagnosis, you know, like cancer,
staging or something, and that diagnosis drives the main treatment protocol.
Regional stuff like hypertension, it just modifies the plan. It
doesn't drive the whole strategy precisely.
Speaker 2 (02:39):
And in dentistry, look that regional approach. It used to
be okay because frankly, our tools were more limited. But
things started changing back in the early eighties. The focus
shifted towards what they called facially generated diagnosis, okay, prioritizing
tooth position aesthetics. The belief was function would kind of follow,
and they really zeroed on the position of the incisile edges.
Speaker 1 (03:02):
But even that approach, the one focus just on the
incisile edges, it had a pretty major flaw, didn't it.
Speaker 2 (03:06):
Oh, absolutely, you could get.
Speaker 1 (03:07):
Those biting edges perfectly lined up, step back and realize
the whole smile was still well an aesthetic mess. Why
was the gingeeba the missing piece there?
Speaker 2 (03:17):
Because the incisile edge position. It's only half the story.
It's just not enough. The global diagnosis system forces you
to recognize that if the gingevile tissues and the overall
smile frame are unacceptable, think uneven gum levels or that
really excessive gingevil display the gummy smile, then the whole
result is basically an esthetic failure. No matter how perfect
(03:39):
the incisile edges are, you have to figure out the
why behind the gingevile problem first.
Speaker 1 (03:45):
So to structure that investigation to find the why, the
sources lay out this tool, the Global Analysis Diagnosis Form
or gad form. It sounds efficient, maybe five minutes to
fill out, but it clicks really specific essential information. It's
pure efficience, honestly, and it organizes things from the outside
in face first, then teeth exactly.
Speaker 2 (04:04):
It directs your focus immediately to the measurements that actually
establish that global diagnosis. Let's maybe focus on five critical
ones from the sources, starting with face height.
Speaker 1 (04:13):
Okay, face height rule of thirds yep.
Speaker 2 (04:15):
Using the classic rule of thirds to check vertical facial proportions.
Speaker 1 (04:19):
So how are we measuring this? What are we looking
for specifically?
Speaker 2 (04:22):
Okay? So you measured the middle third that's from the
globella between the eyebrows down to the subnasal where the
nose meets the upper lip. Got it, And you compare
that length to the lower third, which runs from the
subnasal down to the mint and the tip of the chin.
And crucially this is important, measure it with the patient
and repose lips totally relaxed, not smiling, no, definitely not smiling.
(04:45):
If that lower third measurement is significantly longer than the
middle third, that's a big red flag for a potential
vertical maxillary excess.
Speaker 1 (04:53):
V Amy okay, skeletal discrepancy makes sense. Moving inward. Then
the second metric is lip length and mobility. We need
numbers here, right we do.
Speaker 2 (05:02):
The sources give averages. For a young woman, upper lip
length is typically around twenty to twenty two millimeters, men
usually a millimeters or two longer.
Speaker 1 (05:10):
And mobility.
Speaker 2 (05:11):
Mobility is how far that lip travels from repose to
a full maximum smile. Normal is about six to eight millimeters.
Speaker 1 (05:17):
And getting that full smile is key, I imagine.
Speaker 2 (05:20):
Absolutely critical for diagnosis. You might need to get the
patient to actually laugh genuinely or use tricks like the
high E rule. Having them say eee, to really stretch
the lip up, you need to see the maximum movement.
Speaker 1 (05:32):
Okay. Third, we look at the central incisor exposed and
repose our baseline reference.
Speaker 2 (05:38):
Yes, and this is a huge diagnostic clue. A young
woman on average shows about plus three to plus four
millimeters of a central incisor when.
Speaker 1 (05:46):
Her lips are relaxed, and a young man.
Speaker 2 (05:48):
Typically plus one to plus two millimeters. And this also
helps us understand aging effects. You know how so well,
the upper lip tends to lengthen by about one millimeters
per decade after age forty, so you see less incisile
display as people get older.
Speaker 1 (06:02):
At all connects interesting fourth metric the dental facial mid
line right.
Speaker 2 (06:07):
Ideally this should be perpendicular to the horizon, lined up
with a facial mid line off and running through the
little dip in the upper lip, the cube its bow tip.
Speaker 1 (06:14):
How much wiggle room is there?
Speaker 2 (06:16):
Well, a small deviation, say less than two millimeters off
the facial mid line often acceptable. Most people won't notice it. However,
the authors are really clear on this. A can't meaning
the whole mid line is tilted relative to the horizon.
That's visually unappealing. To pretty much everyone dental pro or
not that needs correction.
Speaker 1 (06:34):
Okay, a cant is a definite problem. And finally number five,
this sets up the gingible diagnosis. Checking the CEJ location
the cemento enamel junction.
Speaker 2 (06:44):
This is absolutely fundamental in a healthy situation where the
anatomical crown is fully exposed. You should be able to
gently feel that distinct texture Chaine smooth enamel to rougher
cementum right at the CEJ when you probe the sulcus.
Speaker 1 (06:57):
And its position relative to the bone.
Speaker 2 (06:59):
That's the key anatomical marker in health. The CEJ should
set about two millimeters coronal, meaning above the crest of
the alveolar bone. Remembering that specific two milimeter relationship is
what confirms diagnoses like ape later on.
Speaker 1 (07:12):
Okay, So that detailed data from the giadoosan form. It
acts like a funnel guiding us into these five core questions.
These questions, they're really the heart of the system, aren't they.
They force you to use those measurements to land on
a definitive global diagnosis and from there the treatment plan.
Speaker 2 (07:29):
Exactly they translate the numbers into a diagnosis. Let's walk
through them. Please, Question one what are the facial proportions
and skeletal relationships? So, if that GD data showed the
lower third was significantly longer than the middle third, EM
diagnosis vertical maxillary excess VME means the maxilla grew too
much vertically. Since it's a skeletal problem, the definitive primary
(07:51):
treatment is surgical a maxillary la fort on maction orthognatic
surgery to physically move the maxilla up makes sense.
Speaker 1 (07:59):
Question two, what are the length and mobility of the
upper lip? So if filip is short, or if it
moves more than that normal eight millimeters, creating that gummy smile.
Speaker 2 (08:07):
Then the diagnosis is either short upper lip or hyperactive
upper lip.
Speaker 1 (08:10):
And the primary treatment here less invasive usually.
Speaker 2 (08:13):
Yeah, because these are soft tissue issues, or perhaps muscle
activity issues. For hyperactive lip, maybe botox injections to calm
down the muscle movement. For a genuinely short lip, you
might consider dermal lip fillers to add a bit of
vertical length. At rest, behavior modification techniques are sometimes mentioned too, that.
Speaker 1 (08:30):
These are masking if the real issue is VME.
Speaker 2 (08:33):
Absolutely, if the underlying cause is skeletal VME and the
patient decline surgery these are just camouflage options. Important distinction.
Speaker 1 (08:40):
Got it? Question three? What is the relationship between the
gingible line and the horizon? What if that line looks
scooped out like concave or it's canted tilted.
Speaker 2 (08:51):
That pattern suggests the teeth and the bone supporting them,
the dental of the older complex have actually super erupted
or over erupted.
Speaker 1 (08:58):
Downwards, leading to the diagnosed.
Speaker 2 (09:00):
Dental O the older extrusion or GAE. And for this
the authors strongly strongly recommend orthodonic intrusion as the primary.
Speaker 1 (09:07):
Treatment, not surgery.
Speaker 2 (09:09):
They argue against functional crown lengthening surgery in this specific
DEAE scenario, mainly due to potential negative consequences we can
touch on later. Ortho intrusion is preferred, okay.
Speaker 1 (09:19):
Question four, what is the length of the maxillary central
incisor if it's noticeably short the book says less than say,
ten to eleven millimeters.
Speaker 2 (09:28):
Then you start thinking about one or three main causes microdoncha,
just genetically small teeth, attrition, wear and tear, or altered
passive eruption APE and question five is the decider right?
Speaker 1 (09:39):
Question five is the CEJ palpable in the gingevil sulcus.
So if the tooth is short and you probe that
sulcus and cannot feel the CEJ.
Speaker 2 (09:48):
BINGO, that confirms the diagnosis of altered passive eruption APE.
It means the gum tissue in the bone underneath fail
to migrate apically to the correct position during tooth eruption,
leaving part of the anatomical crown still covered up.
Speaker 1 (10:00):
Wow. Okay, so that's the power. The gad form takes
what might seem like just a gummy smile or a
short teeth complaint and gives you a highly specific singular
diagnosis like APE or DAE, and then the system pretty
much eliminates the guestwork by telling you the exact tool,
the exact interdisciplinary approach needed. Let's look at APE. How
that diagnosis points directly to esthetic crown lengthening surgery.
Speaker 2 (10:22):
Right, Esthetic crown lengthening surgery is indicated only for APE.
Its sole purpose is aesthetic to uncover the correct amount
of anatomical crown, getting the gingerble margin back to its
biologically intended level relative to the CEJA, and the sources
are incredibly precise about the surgical goals. There are three. First,
you thin the bone and move its crest to be
exactly two millimeters apical to the ceja.
Speaker 1 (10:44):
Okay, two millimeters below the ceja.
Speaker 2 (10:46):
Second, you position the new gingeral crust three millimeters coronal
to that new bone crest. That establishes the biologic width.
And third, obviously you level the tissue across the teeth
involved for a harmonious look.
Speaker 1 (10:58):
That precision is key, and it makes clear that this
ape surgery is totally different from functional crown lengthening, right.
Speaker 2 (11:04):
Completely different purpose and technique. Functional crown lengthening is purely
for biomechanical reasons. Maybe you need more tooth structure for
a crown to grab onto the feral effect. Or you're
treating a fracture that goes below the gum line. It
often involves different flap designs, maybe moving the gum tissue
apically onto the root surface, exposing cementum. Things you would
(11:25):
never do if your only goal was improving esthetics in
an ape case.
Speaker 1 (11:28):
Okay, crucial distinction. Let's swing back to dental aveular extrusion DAE,
the diagnosis where teeth have overrupted, you said, The authors
strongly prefer orthodontic intrusion over surgery why the strong stance
against surgery here.
Speaker 2 (11:43):
Well, think about it. If you try to do functional
crown lengthening on a tooth that has dae, meaning the
tooth and the bone around it have erupted too far down,
you're forced to remove a lot of bone and gum
tissue just to get the gum line back up. You're
not just uncovering the normal anatomical crown like an ape,
essentially cutting away tissue and bone from an already normally positioned, potentially.
Speaker 1 (12:04):
Long root surface, leading to problems.
Speaker 2 (12:06):
Yeah, big problems. You dramatically worsen the crowned root ratio,
making the tooth potentially less stable, and esthetically you often
end up with those really long, triangular looking restorations with
black triangles and unstable gum margins. It's generally not a
good outcome.
Speaker 1 (12:22):
So the orthodonic solution aims for absolute intrusion. What does
that mean exactly?
Speaker 2 (12:27):
It means moving the entire complex the tooth, the bone
around it, the attached gingiva bodily upward back along its
long axis. You're restoring the proper amount of tooth display
and leveling the gingevile line relative to the horizon, but
without surgically removing tissue.
Speaker 1 (12:43):
How do they control that movement so precisely?
Speaker 2 (12:46):
Often with temporary anchorage devices or tads, little mini implants
placed temporarily in the bone. They provide a stable, unmoving
anchor point to pull against, which allows for that controlled,
predictable absolute intrusion of teeth or segments, rather than just
tipping them, which is relative intrusion.
Speaker 1 (13:03):
Okay, that makes sense. Now let's flip the script entirely.
What about the opposite problem, not short teeth or gummy smiles,
but treating long teeth due to gingible recession.
Speaker 2 (13:12):
For recession, the key guide for predictability is the Miller classification.
Speaker 1 (13:16):
You need to know it remind us.
Speaker 2 (13:18):
Classes I in two generally mean you can expect complete
root coverage with grafting, usually a connective tissue graft. Class
three suggests only partial coverage is likely, and class four
basically means no root coverage is predictably achievable with grafting alone.
So the treatment decision, whether it's just restoration, grafting, or
maybe both, depends on assessing five things where the recession is,
(13:42):
how thick the gum tissue is, how deep the recession
defect is how much root is exposed, and importantly that
Miller classification.
Speaker 1 (13:49):
Okay, very systematic. Again, lastly, let's talk sequencing. Complex cases
often need multiple specialists. If a patient has ape needing
surgery and they also need ortho and restorations at afterwards,
how does this system dictate the timing.
Speaker 2 (14:03):
Timing is absolutely critical for the best outcome. The guideline
is that the esthetic crown lengthening surgery to correct the
ape should ideally happen about six months before the orthodonist
plans to remove the braces or appliances.
Speaker 1 (14:14):
Six months prior.
Speaker 2 (14:15):
Why then, because doing the surgery first levels the gingeeva,
establishing the correct final gum heights. This gives the orthodonist
a clear target. They can then move the teeth precisely
into their final apicocronal positions relative to that ideal gingeble line.
It completely removes the guesswork later on for the restorative
dentist when they're trying to figure out the final ideal
(14:38):
height to width ratios for veneers or crowns. Everything lines
up predictably.
Speaker 1 (14:42):
This system really does seem to demystify these complex interdisciplinary cases.
Speaker 2 (14:47):
It does.
Speaker 1 (14:47):
It forces you the clinician to stop just looking at
individual teeth and instead diagnose that root etiology, the why
behind the gingevile position. First, it provides that structured roadmap
for systemmadic care.
Speaker 2 (15:00):
You never start treatment until you know the destination.
Speaker 1 (15:03):
Exactly ensure as you know where you're going.
Speaker 2 (15:05):
And it's worth remembering too that while the core diagnoses
often point towards surgery or orthodontics, the system doesn't ignore
non surgical management when appropriate. For instance, you might diagnose
definitive VME, but the patient absolutely refuses orthognetic surgery. The
system acknowledges you can still use tools like botox and
dermal fillers dental facial plastics as pretty effective masking procedures
(15:29):
to reduce the gingible display and improve esthetics even if
you aren't correcting the underlying skeleton.
Speaker 1 (15:34):
It really highlights how interconnected all these facial esthetic elements are. Bone, muscle,
soft tissue, teeth. All right, To wrap this up, let's
leave our listeners with a quick thought exercise something that
pulls directly from that five core question structure we discussed.
Speaker 2 (15:49):
Good idea.
Speaker 1 (15:50):
Okay, imagine this, A twenty five year old female patient
comes into your office. Her chief complaint might be short teeth.
You measure her maxillary central in size and they are
indeed short, only eight millimeters long, well blow average. Now,
during your clinical exam, you gently probe the gingible sulcus
around those centrals with an explorer, but you cannot feel
(16:12):
that distinct, slightly rough transition of the cemento enamel junction.
It feels smooth all the way down.
Speaker 2 (16:18):
Okay.
Speaker 1 (16:19):
So, based on those specific data points, short clinical crown,
non palpable CEJ in the sulcus, and thinking back to
the five core questions, what is the most likely global
diagnosis here and what is the indicated primary treatment?
Speaker 2 (16:31):
Yeah, think about that crucial link short crown plus absence
of the CEJ feeling in the sulcus, what developed metal
process likely went wrong, and what specific surgical procedure is
designed only for that exact anatomical situation.
Speaker 1 (16:44):
Mull that over. Think about the system, the structure, the etiology.
It forces you to find. That really is the power
of global diagnosing.
Speaker 2 (16:50):
It brings clarity, it really does.
Speaker 1 (16:52):
We'll catch you next time for another deep dive.
Popular Podcasts
CrimeLess: Hillbilly Heist
It’s 1996 in rural North Carolina, and an oddball crew makes history when they pull off America’s third largest cash heist. But it’s all downhill from there. Join host Johnny Knoxville as he unspools a wild and woolly tale about a group of regular ‘ol folks who risked it all for a chance at a better life. CrimeLess: Hillbilly Heist answers the question: what would you do with 17.3 million dollars? The answer includes diamond rings, mansions, velvet Elvis paintings, plus a run for the border, murder-for-hire-plots, and FBI busts.
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.