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A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position by Dr. Chad Foster

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A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position  

by Chad Foster, DDS, MS, editorial director

The position of the upper incisors within the lip frame is arguably the most dominant feature in the world of smile aesthetics. This topic has been thoroughly expounded upon by two of my personal orthodontic heroes, Drs. David Sarver and Tom Pitts. In this month’s column, I’d like to share a case where that feature became of singular importance during treatment.

To provide some background, I find that Class 3 patients will often show some degree of limited vertical upper incisor display, which negatively affects smile aesthetics. On cephalometric X-rays, you will often see upper incisors stepped up relative to the occlusal plane; their active eruption was insufficient because of the relatively more forward-positioned lower incisors (which led to earlier, and thus incomplete, eruptive contact of the later-erupting upper incisors). Interestingly, I find the opposite is true for Class 2 patients or patients missing a lower incisor—they can often show mild overeruption of the upper incisors that when extreme shows a gummy smile, but when mild often places upper incisors in a more ideal vertical position aesthetically.

Also, from a mechanics standpoint, it can be challenging to improve deficient vertical incisor display for Class 3 patients in particular. In these cases, Class 3 elastics have a tendency to produce unfavorable tipping of the occlusal plane—up in the anterior and down in the posterior. This is exactly opposite of how you’d want to affect the occlusal plane to benefit incisor display when it is deficient. On the other hand, the mechanics involved in occlusal correction of Class 2 patients and open-bite patients are much more favorable for increasing vertical incisor display.

Patient case

For this patient (Fig. 1), in addition to occlusal correction, aesthetic upper incisor vertical position was highly prioritized in treatment planning. At the bonding appointment, I tried to position my bracket heights to facilitate altering the occlusal plane in favor of upper anterior extrusion and lower anterior intrusion. I bonded upper incisors more gingival and upper posteriors more occlusal with a graded divergence. Lowers were bonded with the opposite divergence—more incisal in the anterior and gradually more gingival in the posterior.
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 1


After leveling the arches in this specific bracket height setup, the upper incisor display improved, but not enough. About nine months into treatment, I decided to further exaggerate this effect by stepping the archwires down at U2–2, L2–2 and L3–3. The further effect of this is shown in Fig. 2, the one-year records. The display of the upper incisors within the smile improved, as evidenced in her smile, but again I felt it was not enough. At 13 months into treatment (Fig. 3), I placed TADs between L3–4s to help further intrude the lower anteriors (through indirect and direct anchorage at different times), which enabled further and satisfactory upper anterior extrusion.
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 2
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 3


The case finished in 22 months (Figs. 4–7). In retrospect, if alignment and occlusal objectives had been the only criteria, the case was fully complete at about 10 months. If we had wrapped up treatment at that point, would mom and daughter have been happy with the treatment? Yes—without a doubt, they would’ve been very happy with “straight teeth” and a “fixed underbite,” which are why they pursued orthodontic treatment to begin with.
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 4
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 5
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 6
A Voice in the Arena: Aesthetic Importance of Upper Incisor Vertical Position
Fig. 7


However, also without a doubt, the full beauty of the patient’s upper incisors would never have seen the light of day. With a microaesthetic form worthy of dominating and characterizing the beauty of her smile, they would not. Additionally, as we know from long-term evidence, whatever deficient vertical show that remained would only decrease further with aging. She would never know what could have been with her smile.

 Conclusion

This case isn’t presented to advocate placing TADs and taking on a longer and more complicated treatment for every patient lacking in upper incisor vertical display. I certainly don’t for every such patient in my practice! However, this specific aesthetic benefit is not rocket science; when properly educated about what’s possible, most patients “get it” right away. I now find that most that do are more than willing to accept a longer treatment and significantly larger financial investment to achieve that specific treatment goal. And it’s fun! In the world of aesthetic dentistry, no dentist is better positioned to enhance aesthetics and change lives than an orthodontist.

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