A Restorative Approach to the Clinical and Aesthetic Management of Adult Patients with Class II Division 2 Incisor Malocclusions - Martin Kelleher
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RestorativeDentistry
Arijit Ray-Chaudhuri
Richard J Porter and Martin GD Kelleher
A Restorative Approach to the
Clinical and Aesthetic Management
of Adult Patients with Class II
Division 2 Incisor Malocclusions
Abstract: A Class II division 2 incisor malocclusion may be a cause of aesthetic and/or functional concern for some affected patients. Their
particular concerns may include dark spaces around the misaligned teeth or uneven gingival contours. Orthodontic and/or orthognathic
treatment can address some of these problems but frequently involves lengthy and expensive treatment in the adult dentition. Sadly, such
treatment often produces an unstable result, with significant drawbacks such as the requirement for long-term retention. This article aims
to describe alternative strategies for managing patients with this incisor malocclusion.
Clinical Relevance: This paper outlines a quicker, pragmatic and minimally destructive restorative treatment alternative to conventional
orthodontic treatment and the associated long-term retention.
Dent Update 2012; 39: 684–693
A Class II division 2 incisor malocclusion The purpose of this paper is to
may be defined as: discuss some of the perceived undesirable
features of this malocclusion and
‘The permanent mandibular demonstrate a sensible restorative solution,
incisors occluding posterior to the cingulum with some clinical examples being given.
plateau of retroclined permanent maxillary In addition to retroclined
incisors.’1 maxillary central incisors, the Class II
division 2 (II/2) patient typically presents
with maxillary lateral incisors which are Figure 1. Retroclined upper central incisors with
Arijit Ray-Chaudhuri, BDS, MFDS proclined and mesio-labially rotated mesio-labially rotated upper lateral incisors.
RCS(Ed), MJDF RCS(Eng) LLM, AHEA, (Figure 1).
Specialist Registrar in Restorative Less commonly, all four maxillary
Dentistry, King’s College Dental Hospital, incisors may be retroclined, which may
London, SE5 9RW and St George’s result in retroclination of the mandibular
Hospital, London, SW17 OQT, Richard J incisors and relative prominence of the
Porter, BSc, BDS, MFDS RCS(Eng), FDS maxillary canines (Figure 2).
RCS, Consultant in Restorative Dentistry, The features of this malocclusion
St George’s Hospital, London, SW17 OQT often give rise to a minimal overjet and,
and Martin GD Kelleher, BDS, MSc, FDS together with an increased overbite, may be
RCPS, FDS RCS, Consultant in Restorative deemed to be traumatic to the palatal and/
Dentistry, King’s College Dental Hospital, or lower labial gingivae (Figure 3). Figure 2. Retroclined upper central and lateral
London, SE5 9RW. Poor dental aesthetics may be incisors with prominent upper canine teeth.
684 DentalUpdate December 2012RestorativeDentistry
an overall aim to improve patients’
and others’ perceptions of dental
attractiveness. Treatment usually involves
the use of sophisticated fixed appliances
for a considerable period, depending on
the severity of the malocclusion, followed
by long-term or indefinite retention,
sometimes referred to (erroneously) as
‘permanent retention’.
Figure 3. ‘Traumatized gingivae’ on the labial Many patients elect not to
aspects of the lower anterior teeth due to poor undertake this type of treatment, either
oral hygiene and an increased overbite. because they do not find it acceptable
or because they are unable to access
such care. For these, and indeed for all
such patients, it is reasonable to consider
an acceptable cost-effective alternative
solution, one of which is restorative.
This restorative solution has
the advantage of requiring a much shorter
active treatment and, importantly, as the
option presented is minimally destructive
of dental hard tissues, comes at a very low
Figure 6. An adolescent patient with mandibular
‘biological cost’ (Figures 4 and 5).
Figure 4. A patient with a Class II division 2 retrognathism.
malocclusion and significant tooth surface loss
affecting the upper incisors prior to restorative
dental treatment. A summary of Class II division
2 malocclusions who develop a Class II division 2 incisal
Prevalence relationship usually have a normal or a
The Class II division 2 incisor mild Class II skeletal relationship due to
set-up had not been reported to be mandibular retrognathia (Figure 6).7
common within any study population. A more severe discrepancy
Class I and Class II division 1 relationships tends to produce a Class II/1 relationship
are the most frequently encountered because the lower lip cannot contact
malocclusions, with Class II division the upper incisors to retrocline them, as
2 having a prevalence of 9–13% in described below.
Figure 5. The same patient after restorative dental Caucasian children and adults.4-6
treatment. The benefit to the patient is that he/ Soft tissue characteristics
she gets rid of perceived aesthetic problems at Class II division 2 patients
Aetiology
minimal biologic cost and a reasonable financial are known to present with different
The precise aetiology of a Class
cost. lip shapes, positions and thicknesses
II division 2 malocclusion is not always
by comparison to patients who have a
clear but appears to be multi-factorial. A
Class I malocclusion (Table 1). Class II
a significant concern for patients with a summary of the common causative and
division 2 patients are also reported to
Class II division 2 incisor malocclusion. It associated factors is described below.
have an elevated lower lip-line, as well
has been observed in some studies that This is not an exhaustive list for which
as increased lip to labial surface contact
an uncrowded and symmetric anterior the reader is referred to the standard
with the maxillary central incisors, thereby
dentition is considered to be visually textbooks.
providing a significant and constant
pleasing to those rating the smiles.2 Not retroclining force.8 The authors of this
only is a harmonious dental relationship Skeletal relationship study found that an average of 5.1 mm of
considered attractive, but it is also known Modern radiographic imaging the upper central incisors were covered
to be important in how others observe has added to the debate on the existence by the lower lip in the Class II division 2
personality, success, and even how patients of a ‘pathognomic skeletal pattern’ and this group, by comparison to 2.7 mm in the
view their ‘self image’.3 is still the subject of discussion, although control group. For some patients this is
Orthodontic therapy has often some tentative conclusions may be drawn the prime aetiological factor, whereas in
been provided to correct these aesthetic from the literature. others it appears that this is a function of
concerns, followed by retention, with Children and adult patients the skeletal abnormality.
December 2012 DentalUpdate 685RestorativeDentistry
Patients who have a Class II division these, even if present. temporarily applying, sculpting and curing
2 incisor malocclusion tend to have Patients’ commonest concerns composite material on to the problem areas.
different: relate to: It allows the patient and the practitioner
1. Lip shapes Retroclined upper central incisors; to make subtle changes because this
2. Lip positions Prominent upper lateral incisors; composite mock-up can be left in position
3. Lip thicknesses Sore and inflamed upper and/or lower for quite a number of hours before it falls
‘gums’; off. This allows the patient to discuss the
Table 1. Soft tissue differences between Class II An overall lack of satisfaction with their potential aesthetic result with friends,
division 2 and patients with other malocclusions. smile. family and others. The authors favour this
approach to the alternative, which is to use
articulated diagnostic wax-ups of models
Smile concepts and of the teeth made in a laboratory. These
Dental-alveolar appearance
The Class II division 2 patient
assessment in Class II division suggested changes are then transferred
to the mouth using a putty matrix of the
has a characteristic clinical and radiographic 2 patients wax-up to create a removable chairside
dento-alveolar appearance when viewed A detailed clinical examination mock-up in an appropriately coloured
from the front. The lateral incisors often is required prior to any treatment in the bisacrylate resin. This alternative may be the
appear to be shorter than the central ‘aesthetic zone’. Sadly, while opinions preference of some clinicians, although it
incisors because they escape the control of are common in this field, there are few requires an additional appointment and a
the lower lip and stay proclined. The upper objective criteria for the assessment of laboratory fee is incurred before the patient
labial segment is often imbricated and the smiles and the lip-to-teeth relationships. has any real understanding of the proposed
lateral incisors tend to be crowded out This lack of reliable biometric data treatment.
and frequently have mesio-labial rotations. sometimes means that clinicians have little It is also important to consider
This dental set-up, coupled with a Class choice but to rely heavily on past clinical that a Class II division 2 relationship is not
2 skeletal relationship, often means that experience and their ‘subjective judgement’. necessarily unaesthetic per se and can be
upper and lower incisors do not contact It is important to gain an compatible with different individual’s ideas
effectively in the intercuspal position and in-depth understanding of the concerns of of attractiveness. One should remember
sometimes continue to over-erupt until they the patient from his/her detailed history that restoration of a smile following modern
contact the opposing soft tissues. In the as it is he/she who will be the ultimate European or American images may well not
presence of poor plaque control, this can arbiter of ‘success’. Indeed, research has be acceptable to everyone, especially if they
help to exacerbate gingival inflammation, indicated that orthodontic treatment need are a member of an ethnic minority.
although not necessarily symptoms or does not always correlate well with patients’ It is beyond the scope of this
periodontal disease. This may increase the perceptions of their malocclusion.10,11 It is paper to demonstrate all the components
tendency for the local gingival margins to worth remembering that, in several studies, of aesthetic smile design and, instead, it will
become inflamed or sometimes recede, patient and lay perceptions of treatment focus on the aspects relevant to the Class II
but it is not, in itself, a cause of progressive need have actually been minimal, which is division 2 malocclusion.
periodontitis. sometimes in conflict with the considered For this purpose, smile diagnosis
It has also been reported that opinions of dentists and orthodontists. In will be divided simply into aspects of soft
maxillary central and lateral incisor teeth fact, a patient’s presenting complaint may and hard tissue aesthetics. In the case of a
in these individuals have relatively longer be very different from that envisaged by a Class II division 2 patient, both components
crowns, shorter roots, reduced labio-palatal clinician and may relate more closely to self- are likely to play a role in the overall
thicknesses and altered crown to root image than an objective diagnosis. harmony of a successful result.
angles.9 These dental features, in particular, The authors have found that
may present significant limitations to the a meaningful evaluation of the potential
amount of torque forces that may be placed result of treatment can be achieved quickly Soft tissue aesthetics
on teeth, the rapidity of movements and by using direct composite resin to provide The lips have an important role
limit the overall orthodontic result that may an immediate and entirely reversible in not only contributing to the creation
be achievable. In such cases, a restorative temporary composite ‘mock-up’ directly in of a Class II division 2 relationship, but
solution could be a viable alternative to the patient’s mouth. The patient, or others also in drawing attention away from it.
orthodontics if a patient wishes to avoid concerned about the appearance, can then It is interesting to note that Scott et al
undesirable consequences, such as possible quickly evaluate the proposed changes and concluded that an increased thickness
root resorption or a sub-optimal unstable have a direct input into how they feel about of the vermilion border had a significant
aesthetic outcome. those possible changes. positive effect on the perception of an
The above section provides A Class II division 2 patient who individual’s malocclusion.12 They also
a short summary of likely clinical has expressed a desire for change can gain demonstrated that subjects with thicker
observations, although patients are unlikely a tangible and meaningful representation vermilion borders and mild occlusal
to notice, or express concern, for all of of the end result which can be created by abnormalities were deemed to be more
686 DentalUpdate December 2012RestorativeDentistry
attractive, intelligent, honest and successful the teeth may be deemed by some patients and may be self-limiting as the oro-facial
than others with thinner lips and more to be unaesthetic. These areas are readily soft tissues may lose tone with age. It may
noticeable malocclusions.12 visible post-treatment and may well require be discovered that the patient prefers his/
The lips not only frame a smile careful management to optimize the her current ‘gummy’ yet youthful smile
but also define the boundaries of the margins of any restorations. over a proposed ‘aesthetic’ alternative. It is
‘aesthetic zone’. Lip-lines are classically Not only does the relative over- important to analyse, discuss and document
described as being high, medium or low. eruption of the upper central incisors often in the notes that these discussions have
The medium lip-line is often considered to create a wide band of observable gingivae, taken place as part of the consultation
be the most desirable in western culture but it can also result in irregularity of the process.
and this exists when the lower border of the gingival margins. It is a frequent feature of
upper lip, when smiling, is approximately the smile that, in such cases, the gingival
Hard tissue aesthetics
level with the maximum height of the zeniths of the central incisors are below
The Class II division 2
gingivae (the gingival zenith or apex) of the that of the lateral incisor and canine teeth
malocculsion may have several features
upper anterior dentition.13 Therefore, almost (Figure 9).
which mean it falls short of what is
the entire labial surfaces of the teeth are This is far from ideal as many
considered to be ‘aesthetically ideal’.14
displayed as well as a small amount of the clinicians agree that the gingival zenith of
One of the aims of orthodontic
interdental papillae (Figure 7). central incisors should be level in height
treatment is to create an occlusion that
The Class II division 2 patient with the equivalent points of the maxillary
has no imbrications, which is frequently
typically differs from this and often has a canine teeth. In addition, the supposed
found in both the upper and lower arches
high lip-line and consequently an increased ideal smile would have the gingival zeniths
in this malocclusion. Imbrication of the
amount of gingival display. A relaxed smile of the lateral incisors slightly lower than, or
lower incisors is often considered to be of
may show little or nothing of the over- equal to, this line, but certainly not higher
lesser initial importance than the increased
erupted upper central incisors and ample than it.
overbite and retroclination of the upper
free and attached gingivae, producing the On the other hand, the
centrals, although it may become more
characteristic ‘gummy smile’ (Figure 8). The visibility of the gingival aesthetics may be
noticeable once this aspect of treatment is
obvious display of the cervical portions of considered a trivial concern for the patient
addressed.
The effect of upper anterior
crowding, such as mesio-labial rotation
and proclination of the lateral incisors, is
that other elements of an aesthetic smile
are lost. For example, ideally, there should
be symmetry of the contact points, incisal
embrasures and connector spaces. In
relation to the latter, a 50-40-30 rule should
be observed, ie that 50% of the height of
the central incisors should appear to be
in contact (the connector space) in the
Figure 7. A patient with a medium lip-line with midline, 40% of the height in between the
the upper lip approximately at the cervical Figure 9. A Class II division 2 patient with a high central and lateral incisor and 30% between
margins of the upper incisors. smile displaying the cervical aspects of her upper the lateral incisor and the canine .15 This is
anterior teeth and ample gingivae. It is also of rarely, if ever, the case in Class II division
note that the gingival zeniths of the upper central
2, where there is often no contact point
incisors are more coronal than those of the upper
or connector zone between some or all of
lateral incisors.
the anterior teeth, thereby creating large
unsightly incisal embrasures (Figure 10).
Crowding may also result in the
following problems:
A shift in the dental midlines causing
them to be non-coincident with each other
and/or to the facial midline. Johnston
Figure 8. A Class II division 2 patient with a
and colleagues found that only 56% of
moderately restored dentition and over-eruption
of the upper central incisors and the upper left laypersons, but 83% of orthodontists, were
lateral incisor. The patient does not display the able to notice a midline discrepancy of
incisal edges of his upper anterior teeth on Figure 10. A Class II division 2 patient with 2mm in patients with all forms of incisor
smiling but does display the cervical portions and discrepancies of both contact points and malocclusion. This rose to being apparent to
the associated gingivae. connector zones of the upper anterior teeth. almost all raters if the discrepancy was 4mm
688 DentalUpdate December 2012RestorativeDentistry
or more.16 and clinician would have to accept the relapse. Mild proclination, intrusion
Changes to the incisal edges of the upper overbite, retroclination of the upper and palatal root torque of the maxillary
anterior teeth. Ideally, as a segment the anterior teeth and any crowding in the incisor teeth allows the mandibular
tips of the upper anterior teeth should be lower arch. Thus orthodontic treatment incisors to be proclined into the position
parallel to the inter-pupillary line or follow would be aimed at relief of crowding previously occupied by the maxillary
the lower lip in a relaxed smile.17 in the upper arch and alignment of the incisor crowns, thereby maintaining the
Changes to the longitudinal axes of teeth upper anterior teeth only. Depending incisor crowns within the zone of soft
which, ideally, should be perpendicular to on the molar relationship, this can be tissue equilibrium.
the inter-pupillary line and slightly mesially achieved with distalization of the buccal Retention is always required
inclined as one looks from the apex to the segments or extraction of the upper using either a removable retainer (eg
crown.18 premolar teeth to allow canine retraction. Hawley, Essix, etc), a fixed retainer,
In addition to positional In more marked cases, it or more commonly a combination of
concerns of the teeth in the upper labial may not be possible to accept the the two. The former is dependent on
segment, the morphology of the teeth overbite and/or the upper labial long-term patient compliance and
themselves can contribute to the overall segment retroclination. In these patients, meticulous oral hygiene to prevent
aesthetic problem. Long upper central fixed appliances will be required to plaque stagnation. A fixed retainer may
incisors next to relatively short laterals permit palatal root torque, possibly debond as well as cause difficulty with
tend to violate some perceptions of beauty in combination with lower incisor flossing and therefore requires indefinite
relating to visual tooth proportions in a proclination if the lower arch has mild to review and maintenance with all the
smile. The desired width ratios of teeth moderate crowding. In cases of severe attendant costs. There is, however, no
in the ‘aesthetic zone’ are sometimes said lower arch crowding, premolar extractions compelling evidence that one type
to follow the ‘Golden Proportion’ (Phi), may also be required. Care needs to be of retention is superior to another in
especially in relation to denture teeth in taken with these types of movement as preventing relapse in the incisors in
removable prosthodontics.19,20 This means they are anchorage demanding, may Class II division 2 individuals. Though
that the width of the maxillary central cause root resorption and risk gingival stability may be maintained with
incisor should be in a ratio of 1:0.618 by recession. retention, a retrospective analysis by
comparison to the lateral and the canine In general terms, the greater Canut and Arias illustrated that, within 3
should be visibly narrower than the lateral the severity of a Class II skeletal pattern years, 10% of Class II division 2 patients
by the same proportion. However, it is and the lower the Frankfort-mandibular had unacceptable irregularity of their
essential to note that this applies to the planes angle (FMPA), the harder it is to maxillary dentition.23
perception of the visual width of these achieve an ideal post-treatment result. If the pre-treatment tooth
teeth as viewed from the front, as opposed In adult patients, growth modification position is accepted, however, and
to their actual anatomical width. There is not possible and thus severe skeletal the malocclusion is masked with
has been lots of research into whether discrepancies will have to be accepted or restorations, then the need for retention,
this ratio is apparent in visually pleasing will require orthodontics and surgery. This although not maintenance, is removed.23
smiles and the results have produced mixed usually begins with pre-surgical dento-
conclusions.21,22 alveolar decompensation to convert the
Class II division 2 into a Class II division Restorative management
1 incisor relationship, and maintain the of adult Class II division 2
Orthodontic management curve of Spee. Orthognathic surgery
patients
of adult Class II division 2 would usually involve mandibular
The broad aims of restorative
advancement to a three-point landing
patients (incisor and terminal molar contact only) dental treatment are to accept the
Although the focus of this using a bilateral sagittal split osteotomy position of the roots of the teeth but to
paper is on the restorative management to correct the antero-posterior skeletal camouflage the crowns to produce a
of adult patients presenting with a Class II discrepancy, followed by post-surgical more even and symmetrical appearance:
division 2 incisor relationship, it is important fixed appliance therapy to level the arches The changes may involve using
to remember that orthodontic and/or by mandibular buccal segment extrusion directly bonded layered composite to
orthognathic treatment may sometimes still and make final adjustments to tooth alter the incisal levels by lengthening
be the treatment of choice. positions. the upper lateral incisors mainly on their
Mild Class II division 2 In Class II division 2 patients, palatal surfaces and by shortening the
malocclusions without marked vertical poorly controlled orthodontic treatment tips of the upper centrals to reduce the
or antero-posterior skeletal discrepancies may produce an unstable tooth position excessive height of the central incisors.
may be amenable to treatment of the because the new positions of the teeth Adding direct composite or porcelain
upper arch only, especially if the patient’s violate the equilibrium of the intra- and to the labial contours of the upper
concern is only the aesthetics of the upper peri-oral tissues. This unstable position anterior teeth in order to bring them
anterior dentition. In such cases, the patient means that the teeth will be prone to forward to be more in line with the
December 2012 DentalUpdate 689RestorativeDentistry
lateral incisors. This reduces the effect of Direct composite bonding allows the clinician to judge how such
them being retroclined and being in the Strategic use of direct composite changes could affect lip posture, incisal
shadows of the upper lateral incisors. can offer a sensible solution to some display and phonetics. More importantly,
Altering the gingival contours, by raising patients who are concerned about their dark it allows clinicians a chance to observe
the gingival zeniths of the upper central spaces and a mild or moderately crowded the patient’s non-verbal reaction to these
incisors to be at the level of the canine dentition. proposed changes.
teeth and also restoring the appropriate In order to assess the Prior to undertaking this
gingival embrasures. acceptability and limitations of directly mock-up, the teeth should be cleaned
The hard and soft tissue bonding composite to camouflage the teeth, and dried and then composite of an
management options available to achieve the unset composite material can be placed, appropriate shade can be sculpted on to
these aims include: shaped and light-cured, without etching or particular areas of the teeth to disguise
Direct composite bonding; bonding. This gives patients a realistic and the misalignment and block out the dark
Gingival recontouring; readily visible change. It is quick, reversible spaces. Most frequently, composite will
Porcelain laminate veneers; and a risk-free way of assessing the visual need to be placed on the palatal aspects
Any combination of the above. effects of the proposed smile change. It also of the lateral incisors and separately on to
the whole of the labial aspect of the central
incisors (Figures 11–16).
To optimize the aesthetic result,
the edges of the central incisors may be
shortened and the visual effect of doing
this can be gauged directly by using a
black permanent ink marker pen (eg
Staedtler®). Application of this felt-tip pen
to the dried edges of the central incisors
can illustrate to the patient the visual
effect of greater or lesser shortening of the
Figure 11. The patient with composite bonded Figure 14. The patient with composite bonded central incisor tips. This allows the patient,
on to the labial aspects for the upper central on to the upper canine teeth. A practical tip for and any interested third parties, to assess the
incisors. directly ‘mocking-up’ composite is to support the appearance of such temporary shortening
material with a gloved finger palatally and to use (Figure 17). The ink can easily be removed
a small brush dipped in resin to smooth the labial with surgical spirit.
surfaces. Once the patient is satisfied
Figure 12. The directly bonded composite
should be light-cured as per the manufacturer’s
instructions.
Figure 15. The composite material can be
Figure 17. A patient with ‘permanent’ ink drawn
smoothed with polishing discs.
on the incisal edges of their upper central incisors
to illustrate the effect of shortening.
Figure 13.The patient with composite bonded
on to the upper lateral incisors. It is of note that Figure 16. The completed composite ‘mock-up’ to
in this case the majority of the composite was illustrate what is achievable without orthodontic Figure 18. A study cast of the ‘mock-up’ to aid the
bonded to the disto-labial aspects of these teeth. treatment. definitive composite placement.
690 DentalUpdate December 2012RestorativeDentistry
Advantages Disadvantages
Excellent aesthetics possible May not be possible in crowded arch
Resistant to staining May be destructive of sound tooth tissue
High tissue compatibility Requires at least two visits
High success rates if preparation is in enamel Requires excellent laboratory support with
the associated costs Figure 19. A patient with a Class II division 2
Table 2. The advantages and disadvantages of porcelain laminate veneers in Class II division 2 patients. incisal relationship with missing upper lateral
incisors and retained upper deciduous canine
teeth.
with the mock-up a photographic record to the retroclined position of the central
and impressions should be taken to allow incisors, the indirect veneering technique
accurate reproduction of the effects is predominantly additive and avoids
(Figure 18). the need for much, if any, labial axial
In the majority of cases, the reduction. Preparation is often only
composite will be retained long enough needed with a small chamfer finish line at
for the patient to have a few hours with the the cervical region to guide the ceramicist,
material in position in order for him/her to but allowing for sufficient thickness of
seek opinions from friends and family. They material and an appropriate emergence
may be instructed on how to flick off the profile. However, preparation of proclined
Figure 20. The patient receiving a simple
composite or offered the option of returning lateral incisors can be destructive, unlike
gingivectomy of the upper central incisors.
the next working day to have this done by the approach with direct composite. With
the dentist. regard to aesthetics and contour, there
Composite has the advantages should be clear instructions on length,
of being biologically friendly. It requires little translucency, micro-anatomy, etc, assisted
or no tooth preparation and provides a quick by the technician being given models
result. Composite is, however, susceptible and photographs of the direct or indirect
to staining and this can be a problem in mock-up.
smokers. It has to be finished and polished
carefully. It is essential to advise the patient
Gingival contour
pre-operatively that the material is likely to
Much can be achieved with
require repolishing or resurfacing after a
composite or porcelain veneers alone for Figure 21 The patient with definitive porcelain
few years, though this is rarely onerous for
Class II division 2 patients with cosmetic laminate veneers on her anterior and
either the patient or clinician. The costs and
concerns, particularly in relatively mild premolar teeth.
responsibilities involved in doing this should
cases. Some patients with a low lip-line
be discussed and a record kept of these
may have little perceived benefit or
discussions.
desire to have aesthetic improvements
undertaken to their gingival contour. recontouring is often the labial aspect of
Porcelain laminate veneers As mentioned above, a feature the upper central incisors. The margins of
Porcelain veneers offer an of ideal gingival architecture is that the these teeth may be well below the GAL.
alternative to directly bonded composite gingival zeniths of the central incisors, the This soft tissue change can be achieved
and theoretically can offer excellent canines and, possibly, the lateral incisors with either soft tissue sculpting (Figures
tissue compatibility, colour stability and should lie on a line joining these zeniths. 19–21) or both soft tissue and alveolar bone
aesthetics24,25 (Table 2). The single path of This line is known as the gingival aesthetic recontouring, using a conventional flap
insertion required for porcelain veneers, line (GAL). For example, a large vertical technique, electro-surgery or a soft tissue
however, is often compromised by the discrepancy from the GAL of the lateral laser.
presence of the crowded and short lateral incisors in a Class II/2 patient may have a The concept of biological width
incisors. detrimental effect on the overall aesthetic should be considered when undertaking
Porcelain veneer preparations result, producing the appearance of restorative dental procedures which
should be confined to enamel, with minimal inappropriately narrow teeth.26 encroach on gingival tissues, and this is
axial reduction so that pulpal complications In this malocclusion, however, especially important when recontouring
may be minimized. With specific reference the area that requires most gingival bone.
692 DentalUpdate December 2012RestorativeDentistry
Conclusion 6. Proffit WR, Fields HW Jr, Moray LJ. 16. Johnston CD, Burden DJ, Stevenson
Prevalence of malocclusion and MR. The influence of dental midline
Restorative dentistry may be
orthodontic treatment need in the discrepancies on dental attractiveness
able to offer an alternative to orthodontics
United States: estimates from the ratings. Eur J Orthod 1999; 21: 517–522.
for Class II division 2 patients who have
NHANES III survey. Int J Adult Orthod 17. Ahmad I. Anterior dental aesthetics:
aesthetic and functional concerns. Such
Orthognath Surg 1998; 13: 97–106. dentofacial perspective. Br Dent J 2005;
treatment is both time- and cost-effective
7. Karlsen AT. Craniofacial characteristics 199: 81–88.
and comes at a very low biological cost.
in children with Angle Class II div 2 18. Morley J, Eubank J. Macroesthetic
Such a visual benefit is of at least equal,
malocclusion compared with extreme elements of smile design. J Am Dent
if not greater, value to the patient who is
deep bite. Angle Orthod 1994; 64: 123– Assoc 2001: 132; 39–45.
concerned about a prolonged course of
130. 19. Lombardi RE. A method for the
orthodontic treatment which, at the end,
8. Lapatki BG, Mager AS, Schulte- classification of errors in dental
may have poor long-term stability.
Moenting J, Jonas IE. The importance esthetics. J Prosthet Dent 1974; 32:
of the lip line and resting lip pressure in 501–513.
Acknowledgements Class II division 2 malocclusion. J Dent 20. Levin E. Dental aesthetics and the
The authors would like to Res 2002; 81: 323–328. golden proportion. J Prosthet Dent 1978;
thank Mr Neil Poyser, Mr Jamie Gwilliam, 9. McIntyre GT, Millett DT. Crown-root 40: 244–252.
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