It all begins with a smile.......

Since the mouth is one of the focal points of the face, it comes as no

surprise that a smile plays a major role in how we perceive ourselves,

as well as in the impression we make on the people around us. A

charming smile can open doors and knock down barriers that stand

between you and a fuller, richer life.

1
 It's as old as the pyramids

We are not the only people to place a high premium on the smile. In fact,

throughout history many civilizations noted for their achievements in other areas also

demonstrated an interest in cosmetic and restorative density.

For example, two false teeth encircled with gold wire believed to have been designed as

substitutes for missing molars were discovered years ago in the ancient Egyptian

cemetery of EI Gigel. At the height of Mayan civilization, a system of dental decoration

involved filing the teeth into intricate shapes or decorating them with jadeite inlays.

Although times have changed, human nature has not. Fortunately, modern

dentistry not only provides us with better material and technology, but also ensures that

today's procedures are performed with minimum discomfort and maximum safety.

2
 WHAT IS ESTHETICS?

Although the dictionary definition of esthetics-"the science of beauty in nature

and arts"- appeals to our scientifically oriented education, it does not stand up to Hegel's
statement: "Beauty as the substance of the imagination and feeling can not be an
exact science." (Fig.1)
The perception of beauty as a corporal expression can vary from one individual to
another, one civilization to another and from one ethnic group to another. Human beauty
being a subjective factor changes the treatment modules of similar problems from one
patient to another thus disallowing a standardization of the treatment plans.

ESTHETIC DENTISTRY
"Is the art and science of dentistry applied to create or enhance the beauty of
an individual within functional and physiological limits.” The whole face needs to be
considered in totality when trying to work on dental esthetics because the final picture
should be a merger wherein the various features of the face, smile, teeth and gums
complement each other naturally and completely.

Esthetic dentistry strives to merge function and beauty with the values and
individual needs of every patient. Esthetic dentistry involves a certain attitude as well as
artistic ability and technical competence. Tooth colour is obviously essential in the final
result, but esthetic treatment planning should never be devised around shading
improvements alone. Our ultimate goal, as clinicians is to achieve a pleasing composition
in the smile-to create an arrangement of the various esthetic elements to proper
proportion or relation according to known principles.

ESTHETIC PRINCIPLES

Certain esthetic principles can be applied to the dentofacial complex and thus by
combining artistic creativity with science discretion, an esthetically appealing smile
window can emerge.

3
1. COMPOSITION
Vision is possible only if there is contrast. The relationship between objects made
visible by contrasts is called composition, which can be classified as:
a) Dental composition
b) Dentofacial composition
c) Facial composition
2. UNITY
Gives the different parts of the composition the effects of a whole. Unity can be:
a) Static: as seen in inanimate objects like snowflakes and crystals.
b) Dynamic: active, living and growing as in plants and animals. (Fig.2)
3. COHESIVE AND SEGREGATIVE FORCES
a) Cohesive forces: Elements that tend to unify a composition, represented by
elements arranged according to a principle.
b) Segregative forces: Elements that break the monotony of the composition to
provide variety in the unity.
Harmony depends on the equilibrium created by cohesive and segregative forces.

4. SYMMETRY
Refers to the regularity in the arrangement of forces or objects (Furtwangler,
1964). Symmetry can be:
a) Horizontal/running: occurs when a design contains similar elements from left to
right in a regular sequence
b) Radiating: occurs as a result of the design of objects extending from a central point
with the left and right sides being mirror images.
Horizontal symmetry that is psychologically predictable tends to be monotonous
(cohesive forces); where as radiating symmetry generally represents a segregative force
that brings life and dynamism to a composition.
5. PROPORTION & REPEATED RATIO
a) Proportion: To speak of proportion stems from a notion of relationship,
percentage or measure in its numerical determination and implies the quantification of
norms that can be applied to every physical reality.

4
 Various philosophers have desired to prove the hypothesis that beauty could also be
expressed mathematically.
E.g. GOLDEN PROPORTION (Pythagoras): 1/1.618 = 0.618
BEAUTIFUL PROPORTION (Plato): 1/1.733 = 0.577

(Fig.3&4)
The Pythagorean concept can be found in the composition of the great classical
painters and a meticulous analysis of some masterpieces has evidenced its master full
application.
Although by reason of facts proportion is mathematical, it seems more pertinent
today to combine the numerical quantification of beauty with its psychophysical
quantification.

b) Repeated ratio: The division of a surface into parts that contrast in shape and size but
are yet related to each other through a certain repetitive mathematical factor is called
repeated ratio.

6. BALANCE
Stabilization resulting from exact equilibrium between opposing forces. In balance,
weight of the elements further from the fulcrum or center grows in importance. If any
element is imbalanced on one side:
• Move the causative element toward the line of forces or midline to relieve visual
tension.
• Introduce an opposite element along the same line of forces to promote
equilibrium.
(Fig.5)
7. LINES
Many factors that are part of biologic or structural beauty depend on the
visualization of lines. Dental compositions contain a multitude of lines that are more or
less expressed as the occlusal plane, midline or tooth direction.
(Fig.6)

5
8.DOMINANCE
Implies the presence of subsequent similar elements. The stronger the subsequent
element, the stronger the dominating element and more vigorous the composition will be.
Colour, shape, and lines are factors that can create dominance. It is the key factor
required to provide a broadened appraisal of dentofacial composition and the necessity
for a harmonious integration of dental composition into facial structure.

Fig. 1 Beauty is virtual (Plato)

Fig.2 Static Unity Dynamic Unity

Fig. 3 Fig.
Fig. 54
 Fig. 6 Equal lines represent important cohesive forces,
whereas cross lines have a stronger connotation of
segregative forces.

FACTORS OF ESTHETIC DENTOFACIAL COMPOSITION AND THEIR

CLINICAL SIGNIFICANCE

An organized and systematic approach is required to evaluate, diagnose and

resolve esthetic problems predictably.
The two main objectives in Dental Esthetics are:
• To create teeth of pleasing inherent proportions and of pleasing proportions to one
another.
• To create a pleasing tooth arrangement in harmony with the gingiva, lips and face

7
 of the patient.

The esthetic orientation of the dental composition with the entire facial composition
can be achieved by taking into consideration the references, smile elements, proportions
and symmetry.
Four factors of esthetic composition can be simply and effectively be applied to the smile.
They serve to assist the clinician in determining adequate tooth display, tooth size, tooth
arrangement and orientation to the face during esthetic diagnosis and treatment.
• Frame & reference
• Proportion and idealism
• Symmetry
• Perspective & illusion
These factors will be dealt with under various headings relating to the components of
the dentofacial complex, namely:
1. FACIAL COMPONENTS
2. DENTAL COMPONENTS
3. GINGIVAL COMPONENTS
4. PHYSICAL COMPONENTS

1. FACIAL COMPONENTS

1.1 References
The anatomical elements of the face and the biological elements that include the
functional and phonetic elements provide the reference frames and guidelines to help the
dentist to achieve a general sense of orientation and diagnosis.

References can be classified as:

8
1.1 a Horizontal references (Fig.7)
A horizontal perspective of the face is provided by:
• Interpupillary Line
• Ophriac Line
• Commissural Line
The general direction of the incisal plane of the maxillary teeth and gingival outline
must parallel the interpupillary line, whereas the ophriac and commissural lines serve as
accessory lines. This harmony must be further reinforced by the incisal plane following
the lower lip line during smiling. When an imaginary line drawn across the gingival
margins is not parallel to tile interpupillary line, a canting of the maxilla is indicated.
Certain amount of canting is considered normal and in such case a mild correction of the
gingival margin can be done by surgically elongating the central incisor on the lower
aspect. Severe canting may require an inter-disciplinary approach involving orthodontics
and surgical repositioning of the maxilla.

1.1 b Vertical references (Fig.8)

The facial midline is an imaginary line that runs vertically from the nasion,
through the subnasal point and the interincisal point to the pogonion. The T -effect
created by the interpupillary line perpendicular to the facial midline, is emphasized in a
pleasing face, with horizontal elements like the ophriac and commissural lines and with
vertical elements like the bridge of the nose and the philtrum.
The facial midline serves to evaluate:
• the location and axis of the dental midline
• mediolateral discrepancies in tooth position

1.1 c Saqittal References

The contours of the upper and lower lip are part of the profile analysis and can be
used as a guide to tooth positions. Various soft tissue analyses are available for the
assessment of the profile convexity, amount of lip protrusion or retrusion, and

9
prominence. For more complex situations and especially those with skeletal
abnormalities, an orthodontic consultation with cephalometric analysis is strongly
recommended.

Upper Lip Support: Upper lip support is controlled to a certain extent by the position of
the maxillary teeth. The gingival 2/3rd rather than the incisal1/3rd of the maxillary central
incisors, contributes to the main support of the lip. (Fig.9)
According to Pound, tooth position more significantly affects thinner and protruded lips
than lips that are thick, retruded or vertical.

According to Maritato & Douglas cephalometric studies, lip support is a better

guide of tooth position than incisal edge position.

Lower lip relation: The relationship of the maxillary incisal edges to the lower lip is a
guide for the general assessment of incisal edge position and length. When "F" or "V"
consonants are pronounced, the incisal edges should make a definite contact at the inner
vermilion border of the lower lip. These positions are valuable in determining the facial
position of the incisal 1/3rd of maxillary central incisors, which must conform to the path
of closure of the lower lip.

Eline: Esthetic line is an imaginary line connecting the tip of the nose to the most
prominent part of the chin. Ideally the upper lip is 1-2mm behind and the lower lip, 2-
3mm behind the E-line. (Fig.10)

Occlusal plane: The occlusal plane is the common plane established by the incisal and
occlusal surfaces of the teeth and conventionally coincides (with minor variations) with
Camper's plane, which is a plane extending from the inferior border of the ala of the nose
to the superior border of the tragus of the ear.

1.1 d Phonetic references

The phonetic references that aid in esthetic diagnosis are:

10
 • The "M" sound is used to achieve a relaxed rest position. Between "M" sounds,
repeated at slow intervals, the amount of incisal display at rest can be evaluated.

• The "F" or "V" sounds are used to determine the lingual tilt of the maxillary
central incisor length.
• The "S" and "Z" sounds determine the vertical dimension of speech. In this
position, the incisal edges of the maxillary and mandibular anterior teeth come in
near contact and determine the anterior speaking space .The amount of posterior
speaking space varies with the amount of mandibular protrusion necessary to
bring the anterior teeth in contact for the "8" sound. Therefore, in patients with a
Class I or Class II occlusal relationship, the posterior speaking space is greater
than the anterior speaking space. In terms of dental reconstruction, these patients
can usually accept variance in the vertical dimension of occlusion as long as it
remains within the limits of the vertical dimension of speech. Because the
speaking space of patients with Class III occlusal relationship is approximately
the same anteriorly and posteriorly, such patients cannot tolerate as much
variation of the vertical dimension of occlusion because it would interfere with
their speaking space.

1.2 Facial Proportions (Fig.11)

Facial proportions can be different from one individual to another. Proportionate
relationships provide a qualitative value of esthetic appraisal.
Dental, dentofacial and facial compositions contain a variety of relationships that
can be evaluated according to the "golden proportion" in its linear and bilateral values
and the variety of geometric forms. The golden proportion not only symbolizes beauty
and comfort at a primitive level, but is also the key to much of normal physiology. Ideally
proportionate faces express a divine proportion as you compare the width of the nose at
the interdacryon (the bony bridge between the eyes) to the width of the nose at the ala.
This progression continues at the mouth width, to the width of the eyes at the lateral
canthus, and finally to the width of the head at the level of the eyebrows.
From the front view, the face is divided: (Fig.12)

11
 • Vertically into two halves by the facial midline. Vertical lines can then be drawn
from the pupil of the eye to the corners of the mouth.
• Horizontally into 1/3rds. The lower 1/3rd is divided into:

1.3 Facial Features (Fig.13, 14, 15&16)

Skeleton, muscles, ligaments and teeth form a cohesive unit. Abnormal facial
equilibrium, either morphologic or esthetic can be ascribed to two major causes:
• Physiological or programmed aging generating changes in muscle and skin
tonicity
• Pathologic aging generated by accidental traumas affecting the oral cavity.
Facial aging predominantly affects the lower 1/3rd of the face. Pathologic situations
materialized by the loss of the teeth, migration, tooth wear, faulty restorations or tooth
arrangements exhibit profound morphologic changes that directly or indirectly affect the
surrounding structures. Functional disturbances naturally reflect on facial appearance
attesting to the link existing between function and esthetics.
A protrusive outward roll of the upper and lower lip onginating in a loss of skin and
muscle tonicity takes part in the development of facial sagging. A loss of the vertical
dimension of the facial 1/3rd affecting the strength and the extent of the working length
of the infraorbital musculature, predominantly the quadratus labii superioris and
zygomaticus, induces a muscle collapse. When this loss is illustrated by anterior tooth
wear or lack of dentoalveolar support, an inward roll of the upper lip margin toward the
corners can be observed.

12

Fig. 7 Fig. 8
Fig. 9

Fig. 10

13

Fig. 11
14
Fig. 13. Individual in his 30s

Fig.14 Diagramatic representation of

head posture maintanence and balance of
craniomandibular muscles

Fig. 15 Individual in his early

50s. Fig. 16 Diagram simulating loss of
dental support.

Fig. 17

15
 Fig. 18
1.4 Tooth
Visibility
The amount of tooth exposure when lips and lower jaw are at rest is, like body
posture, a muscle determined position. An interesting study related to tooth exposure
according to gender, racial factors, 8ge and lip length elucidated the extreme variability
of this factor.
• Tooth exposure showed an increase from Blacks to Asians and Whites for
maxillary central incisors and for mandibular central incisors from Asians to
Blacks and Whites. (Fig.17)
• People with short upper lips expose the maximum maxillary incisor texture, where
as people with long upper lips expose predominantly lower incisors.

Lip length Exposure of maxillary verticalExposure of mandibular

(mm) incisor central incisor
10-15 392 0.64
16-20 344 077
21-25 218 098
26-30 0.93 1.95
31-36 0.25 2.25

• The study evidenced a significant decrease of maxillary tooth length exposure

relative to age, predominantly between age 30 and 40 years, and a proportionate

16
 increase of mandibular incisor exposure, a situation esthetically, unanimously
rejected. (Fig.18)
• The average maxillary incisor display with lips at rest is 1.91 mm in men and
3.4mm in women.

1.5 Components of the Smile

The individual's ability to exhibit a pleasing smile directly depends upon the
quality of the dental and gingival elements that it contains, their conformity to the rules of
structural beauty, the relations existing between teeth and lips during smile, and its
harmonious integration in the facial composition.
Smiles can be classified as :
• Passive: slight parting of lips showing incisal portions of anterior teeth.
• Active: shows more teeth, some gingiva and negative space with lips slightly
stretched at the corners.
• Laugh: maximum exposure of teeth and gums in ari enlarged smile window.
1.5a Lip Lines
The amount of tooth exposure during a smile depends on a variety of factors like
degree of contraction of muscles of expression, soft tissue levels, skeletal particularities
and design of restorative elements, tooth shape or tooth wear.

Upper lip line. Helps to evaluate maxillary incisors exposed at rest and during smile and
the vertical position of the gingival margins during a smile.
• It can be classified as low, moderate or high depending upon the amount of tooth
or gingival display at rest or during a moderate smile.
• A smile can be termed "toothy" if more than 6mm of incisal display is seen at rest,
or "gummy" if more than 3mm of gingival tissue are displayed in a moderate
smile.

The ideal location of the upper lip height relative to the central incisor is at its gingival
margin or 1mm above it displaying the interdental papilla between the two central
incisors during a moderate smile.

17
Lower lip line: helps to evaluate the buccolingual position of the incisal edge of the
maxillary incisors and the curvature of the incisal plane.

1.5bIncisal Plane
When the incisal edges of the central incisor and the canine are aligned on a
convexity, the incisal plane is convex. When the incisal edges of the central incisor and
the canine are aligned but are longer than the lateral incisor, the incisal plane has a "gull-
wing" configuration. A combination of these two pleasing arrangements is often
observed in the same mouth.

1.5c Smile line

An imaginary curved line passing through the incisal edges of the upper anterior
teeth, usually parallel to the curvature of the inner border of the lower lip. Degree of
curvature of the smile line is more pronounced in women than in men. Youth is expressed
with prominent and welldeveloped central incisors, well-defined incisal embrasures and a
convex or "gull-wing" smile line. A straight smile line is associated with wear and aging

Accessorily, the convexity of the smile line may be restored to distract attention
from displeasing facial features. Riley recommends compensating a pointed chin with a
flatter smile curve, or conversely, balancing a square face with a relatively accentuated
smile curve.
Displeasing patterns include a reverse or concave smile line, or an excessive convexity.

1.5d Upper lip curvature

Is expected to run upward from the central position to the corners of the mouth
depending on the sequence and degree of implication of facial muscles in the
development of a smile.

1.5e Negative space

Can be described as the dark space that appears between the jaws at the corner of
the mouth or around the facial aspect of posterior teeth during laughter and mouth
opening. It contributes to the individualization of the dental composition that IS projected

18
by colour contrast. This lateral negative space that results from the difference existing
between the widths of the maxillary arch and the smile has been described to be in golden
proportion with the anterior smiling segment.

1.5f Smile symmetry

Symmetry can only be perceived in reference to a hypothetical central point or
central midline. It may be horizontal or radiating symmetry depending upon patient
preference. In a natural pleasing smile, pleasing tooth symmetry is found close to the
midline and pleasing irregularity away from the midline, creating a balance between
idealism and diversity.

1.5g Occlusal line or Occlusal frontal plane

The occlusal line can be visualized as being part of the dental, dentofacial and
facial composition. Underlined by the segregate forces of the negative space, it takes part
in a system of coinciding lines.

1.5h Smile dominance

Frush & Fisher and Lombard emphasized the need for the maxillary central
incisor to be of sufficient size to dominate the smile, because any composition is based on
dominance of a major element.
Guidelines for pleasant smile dominance:
• Dominance of the central element. Maxillary central incisors exhibit a strong
presence by their size and form.
• Complementarv subsequent elements: Maxillary lateral incisors and canines
complement the central incisor in terms of proper shape and form.
• Pleasing relative proportion: Although numerically, all proportions of the
anterior teeth do not follow the golden rule, the teeth are so placed, they appear in
suitable proportion with each other.
• Order in composition: Similar recurring ratios are observed in the teeth from the
central incisor to the premolar.
• Dynamism of smile: Well coordinated movements of the lips with the other peri-

19
 oral musculature and corresponding harmonious facial expressions, contribute to
the pleasant face during smile.
• Centralized element for unity: The complexion and texture of the face contrast
with the lip colour, gingiva and teeth leading to a distinct demarcation between
the oral and facial frame.

2. DENTAL COMPONENTS
2.1 Dental midline
Both facial and dental midlines are the necessary vectors that enable esthetic
appraisal through the perception of the parameters of symmetry and balance. Logically,
the dental midline should coincide with the facial midline. However, the lack of
coincidence between the location and direction of the two midlines is no esthetic liability
unless there is a distinct discrepancy. Verticality of the midline is more critical than its
mediolateral position.
Golub cautions against achieving a perfectly centered midline with the face
because it creates too much uniformity. Conversely, a vertical and centered midline may
be used to avert attention from asymmetrical facial features.

Research has statistically demonstrated using the lip philtrum as a reference guide,
that the maxillary midline coincided precisely with the facial midline in 70% of the cases,
and that esthetics was not compromised by a slight deviation from the central midline.
The same study revealed that maxillary and mandibular midlines failed to coincide in
75% of the cases.
Anatomical landmarks like the incisive papilla or the labial frenum are used to
center the midline precisely.

2.2 Tooth proportion (Fig.19&20)

Tooth proportion is computed by dividing the width of the clinical crown by its

20
length, which is ideally 75% to 80% for maxillary central incisors. Below 65%, the
central incisor may appear too narrow, as in Implant crowns or after periodontal surgery.
Above 85%, the incisor may appear too short and square, as in attrition or with altered
passive eruption
• Proportion determined by statistical averages: The average WIL ratio of a
maxillary central incisor ranges from 0.74 to 0.89. Wheeler suggested a
proportion of 0.8 (8.5 mm 110.5 mm) for carving technique and this is consistent
with the averages of 0.8 (8.5mm I 10.4 mm) found by Shillingberg et al, 0.8 (9.0
mm /11,2mm) by Bjorndal et al and 0.76 (8.6 / 11.2 mm) by Woelful

• Proportion determined by face form: There are various theories proposed:

Hall (1887) proposed the "typal form concept' classifying natural teeth into ovoid,
tapering and square categories.
Berry's biometric ratio advocated that the outline of the inverted maxillary central
incisor closely approximates the out line form of the face. He also postulated with
House & Loop that the mesiodistal width of the tooth was 1/16 of the bizygomatic
width,

This geometric theory was challenged when Frush & Fisher (1956) introduced the
"Dentogenic theory" where tooth selection is governed primarily by SAP (Sex, Age,
and Personality).
Scientifically, however, correlating tooth form with facial form has been widely
refuted.

• Proportion determined by dentist and patient Preference: Woodhead and

McArthur separately demonstrated that molds of maxillary central incisors were
narrower mesiodistally than extracted teeth. Kern studied 509 skulls and found the
"biometric ratio" of 1 /16 only on 31 % of skulls. 60% skulls revealed ratios of
1/14 and 1/15. Brisman evaluated preferences of, patients and dentists and found
preference on drawings of the central incisor for 0.75 or 0.80 W/L ratio. On
photographs, however, patients still favored the 0.80 ratio while dentists selected

21
 longer and narrower teeth with a ratio of 0.66, possibly conditioned by denture
tooth selection.

• Proportion determined by anatomic consideration Isolated studies find some

relation between the sizes of the maxillary central incisor anc1 various anatomic
features. However, the evidence remains too thin to strictly correlate the shape of
maxillary central incisor with a facial landmark

• "The Golden proportion” (Fig.21) The application of the golden number to

dentistry was first mentioned by Lombard and developed by Levin. Levin
observed that the most harmonious recurrent tooth-to-tooth ratio was found in the
golden proportion. This implies that the maxillary central incisor should be
approximately 60% wider than the lateral incisor, which in turn should be 60%
wider than the mesial aspect of the canine, the distal aspect of the canine being
obscured from the facial aspect. He further demonstrated that the lateral negative
space, the area that appears between the anterior segment of the teeth and the
corner of the mouth on smiling, is in golden proportion to one half the width of
this anterior segment. He developed a grid to help the prosthodontist detect what
is esthetically wrong in the anterior proportional relationship.

2.3 Symmetry
Dental symmetry relates to the right and left sides of the midline. The goal is to
strike a pleasing balance between idealism and deviation, because naturally esthetic
dentitions do have subtle asymmetries.
Rules of symmetry / asymmetry for maxillary anterior teeth

SYMMETRY
• The dental midline is straight.
• The smile line follows the convexity of the lower lip
• The central incisors are symmetrical

22
 • The gingival margins of the central incisors are symmetrical.
• Incisal embrasures gradually deepen from the central incisors to the canine.
• The incisal plane is either convex, sinuous, or a combination of both.
• Mesial tooth inclinations are more pleasing the distal inclinations.

ASYMMETRY
• The dental midline may be slightly oblique in relation to the facial midline.

• The incisal edges of the central incisors may be slightly misaligned if their
gingival margins are not level.

• Teeth should not be aligned in all three planes of space to suggest alignment; they
should diverge in at least one plane.

• The central incisors may slightly overlap the other or occupy a more facial
position or may be slightly rotated facially.
• A central incisor may be more, mesially inclined than the others.
• The distal incisal angle of the central incisor may be bilaterally asymmetrical.
• Lateral incisor may differ bilaterally in shape inclination, abrasion, and gingival
rotation their margins do not need to be level.
• The labiolingual inclinations of the canines may be slightly asymmetrical.

2.4 Axial inclination (Fig.22&23)

Is the direction of teeth with respect to the central nwlline. There is a definite
mesial inclination of all anterior teeth as well as the premolars and first molars relative to
the midline.
Equilibrium is realized around the central fulcrum. In the natural dentition, we
notice a wide range of deviation from the standard axial incisal inclination. In the
presence of moderate and pleasing axial deviation, these inclinations most often
singularize and enhance the personality, provided an equilibrium or a balance of lines has
been achieved around the central fulcrum. Deviations beyond a certain degree of
equilibrium are invariably rated as unattractive. Also, when equilibrium of axial tooth
inclination has not been achieved in the dental composition, the resulting visual tension

23
may also point out a possible factor of occlusal instability.

Fig.19 The outline of the

Maxillary central incisor is
a combination of a circle, a
rectangle and a triangle.

Fig.20

Fig.21 Fig.22

24
 Fig.23
2.5 Tooth
arrangement:
Anterior teeth, in achieving lip and associated muscle support, enable the fulfillment
of esthetic, phonetic and functional requirements. Phonetic methods use the functional
reference of the maxillary and mandibular anterior tooth relationships to assure
naturalness in the dynamics of speech. Most authors rely on various anatomic landmarks
for the placement of anterior teeth. The position of the incisive papilla could be used as a
solid reference as it has been observed to be little affected by bone resorption.
• The CPC line: (Fig.24) a line drawn from the tip of the canines invariably bisects
the middle of the incisive papilla in 92% of the cases. The distance from this line
to the outer labial surface averages 10.2mm.
• Ortman et al (Fig.25) stated that from the posterior border of the incisive papilla,

25
 this distance averages 1245 mm, with a standard deviation of 3867mm.
• A similar statement was made in reference to the first palatal rugae, the end of
which is located 1.5 to 2mm from the lingual surface of the canine.
• A number of clinicians (Fig.26) (Turbyfill WF, Dourdakis J. personal
communications, May 1989) have observed a constant in the distance measured
from the base of the sulcus to the tip of maxillary incisor. This provides a good
reference to the placement of this tooth in the vertical plane.
• Arch form: (Fig, 27, 28&29.) The individual variations of the arch form have
been arbitrarily classified as square, ovoid and tapered with the multitude of
combinations that nature endows. It appears that each type of arch form assumes a
certain type of tooth position. According to the Academy of Dental Prosthesis,
anterior teeth should maintain some of the irregularities observed in nature. This
is better achieved by tooth placement according to an arch form that assures a
natural variety

Fig.24

Fig.25
Fig.26

Fig.28
Fig.29
Fig.27
Fig. 30 26

Fig. 31
2.6 Gradation (Fig.30&31)
When similar structures are aligned one after the other, they undergo a
progressive visual reduction of size from the nearest to the farthest.
The prerequisite of the "front-back progression" of the teeth is the alignment of
the outline or contour of the buccal surface, incisal 1/3rd, median 1/3rd, and, at a lower
rate, the gingival 1/3rd, as well as the alignment of the incisalmesiobuccal Inclines. The
presence of a poorly shaped tooth, differences in tooth length, gingival disharmonies and
colored restorations create problems with respect to the gradation effect. The buccal
corridor or lateral negative space between the buccal outline of posterior teeth and the
corner of the- mouth helps in achieving gradation effect in progressively altering tooth
illumination. The front-back progression is determined by arch form and a key element or
key tooth, usually the canine or the premolar, is a prerequisite for ensuring the
visualization of the gradation effect.

2.7 Dental morphology

Teeth have generally been defined according to their two-dimensional outline, but
their successful characterization depends on the evaluation and reproduction of three-
dimensional characters.

2.7a Texture
We are able to evaluate texture optically through the amount of light reflected or
deflected. The characterization of the tooth surface is a function of two types of
convexities and concavities:
• Anatomic grooves, facets and prominences that exist in various degrees on any
tooth surface.
• The perikymatae, stippling and rippling that may affect the enamel surface.

27
 The quality of an artificial tooth directly depends upon the blending of light effects
that produce a result similar to that produced by a natural tooth

2.7b Shape of teeth

The average tooth outline can be arbitrarily classified as square, ovoid, tapered
and mixed because of the influence of laws of harmony proposed in 1914 by Williams,
which established a relationship between the contour of the face and the contour of the
maxillary central incisor.

Various theories based on osseous and dental landmarks, soft tissue facial contour
and tooth contour, and colour of the face and tooth contour have been proposed. In the
absence of documentation such as old models or photographs, tooth shape, predominantly
maxillary central incisor, not subject to rigid rules, must be selected according to a basic
tooth design and evaluated and corrected in regard to its integration with the facial
environment.

2.7c Diaqrammatic tooth contour (Fig.32-36)

Description of the average anatomic feature of anterior teeth is important as it
provides the dentist with basic geometric norms, without restricting the esthetic sense.
The influence of a number of authors like Wheeler, Stein, Gypsi, Dawson and Scharer
contributed to the design of the tooth morphologies.

2.7d Mesiodistal width (Fig.37)

This dimension is a much more critical dimension than the incisogingival for
anterior tooth placement. Proximal tooth wear seems to affect the aging population. But
in restoring teeth, one should not consider the adjustment of teeth to age, rather should
strongly recommend that patients be provided with young orthodontic dental elements.

2.7e Incisoqinqival heiqht

This dimensional value is less critical than the mesiodistal width as it seems
highly dependant on clinical situations. Attention is only focused on tooth length when it
passes a certain degree of esthetic tolerance.
28
The primary determinants of incisal length are:
• Length and curvature of upper lip
• Patient preference

The accessory determinants of incisor length are'

• Posterior plane of occlusion
• Average anatomic crown length values for maxillary central incisor
In giving back full youth, disharmonies will seldom originate from tooth width or
length but rather from Inappropriate colour selection, which increases in saturation with
the advancement of age.
The simulation of natural appearance that is advocated by the specialists of denture
prosthetics is clouded by the rule that the teeth in their length, and width should be related
to the patient's age. As a consequence, progressive anterior tooth wear is considered
normal, until TMJ problems make both dentist and patient aware of pathology, well
present during the years but not recognized as such and left untreated. Therefore, the
restoration of anterior teeth in their youthful normality becomes a prerequisite for the
restoration of function.

2.7f Incisal profile

The pleasing aspect of the natural maxillary central incisor lies in its pronounced
facial curvature, in part because it creates varied reflection patterns. The challenge in
relocating the incisal edge is to duplicate its original appearance and still preserve a
comfortable and unrestricted anterior guidance. The incisal edge of the central incisor is
the cornerstone from which the smile is built, because once it is set, it serves to determine
proper tooth proportions and gingival levels.

2.7g Characterization of anterior segment (Fig.38&39)

The SAP concept of Frush & Fisher needs to be re-evaluated.The ineluctability of
anterior tooth wear, along with the age progression, is no longer compatible with the
general desire for youth extension and the therapeutic possibilities of functional
maintenance. Therefore, tooth length should be considered a constant value throughout
the progression of age.

29
 From a morphopsychological point of view, the centrals focalize the concrete
features of personality, strength, energy, authority, magnetism, apathy or retraction, while
the lateral incisors concentrate abstracts like artistic, emotional or intellectual elements of
the personality. Canines express animal aggressivity and danger, directed by ambition
and obstination, which is most often attenuated by age, introducing into the tooth shape a
certain "maturity".

2.8 Contact points (Fig.40&41)

Marginal ridges, marginal fossae and spillways seem to be helpful aids in
preventing food impaction. On the anterior segment and from a frontal view, the contacts
are situated a position that seems to go from incisal to cervical from maxillary central
incisor to canine.

It is generally accepted to locate the contact between centrals at the most incisal
1/3rd, a point that terminate a long vertical interincisal line of contact. This line serves as
a reference for symmetry and balance of the two sides. If an imaginary line is drawn
between the anterior contact points, it forms a curvature that greatly reinforces the curve
of the incisal line and the lower lip line.
The directional coincidence of contact, incisal and lower lip line provides cohesive forces
to the dentofacial composition. At the same time, the degree of curvature introduces
segregative forces in the composition.

2.8a Anatomy of the Contact Point

The form of the contact point, or rather contact area, in its oro buccal and
coronoapical extension, is directly influenced by the morphology of the teeth, their width
and arrangement. The oro buccal shape of tooth contact directly determines the shape of
the gingival col, a microscopic depression in the interdental papilla. An orobuccal
broadening of contact area favoring formation of an oversized co I is contraindicated.

2.8b Embrassures or interdental spaces

The cervical portion of the contact area, the interproximal wall of the adjacent

30
teeth and the interdental papilla form the interdental embrassure, a segregative esthetic
factor assuring harmony in the dental composition. The interdental gingiva follows the
shape of the bone. On the anterior region, it appears convex, reduced in width and
producing a pyramidal and knife-edge shape; and it becomes more flat in the posterior
region. The closer the roots, the higher and more convex the interproximal tissues
between them and vice-versa.

Esthetics and accessibility of embrassures for oral hygiene are inversely

proportional. In the posterior area, wide open embrassures favor accessibility for oral
hygiene and sufficient room for the gingiva, but do not allow for lateral food impaction
provided the contact is maintained. In all circumstances, when a normal tooth structure
exists along with adequate interproximal root proximity and a sound periodontal state,
maintenance of the embrassure space depends directly on the amount of preparation,
margin placement, fitness of restoration, emergence profile, interproximal tooth design
and location and width of the contact area.

Fig.32 Fig. 33 Fig.34

Fig.35 Fig.36

31
Fig.37 Fig.38

Fig.39

Fig.40 Fig.41

32
3. GINGIVAL COMPONENTS
3.1 Gingival morphology
The gingiva begins at the mucogingival junction (linea girlandiformis ) and finishes at the
tooth collar. It is divided into free and attached gingival.
The free gingiva is divided into:
• Marginal gingiva: that surrounds the buccal and palatal aspect of the teeth in an
average width of O.5-2.0mm.
• Interdental gingival/papilla: Extension of the free marginal gingiva, the form and
size of which are determined by the contact relationship of the adjacent teeth and
the width of the proximal surfaces.

The attached gingival exhibits the typical orange-peel stippled appearance. The
maintenance of a good, healthy marginal periodontal tissue, providing a pleasing esthetic
appearance, requires a minimal width of 2mm of attached gingiva. Pigmentations are
confined to attached gingiva.
3.2 Gingival contour
The normality of gingival contour is judged according to four subsidiary factors:
3.2a Embrassures
In healthy individuals, the gingival tissue blends into the tooth embrassure, which is
totally filled from buccal to lingual. Unfortunately, it tends to appear, usually following
gingival recession or periodontal therapy, by the development of a black triangle.
Restoration of embrasures is crucial in esthetic dentistry.
3.2b Ginqival zenith (Fig.42)
The most apical point of gingival tissue is located distal to the long axis of the tooth on
maxillary central incisors and canines, while on the maxillary lateral incisors and
mandibular incisors, it is located along the long axis.
3.2c Ginqival heiqht (Fig.43&44)
Class I
In Class I occlusion tooth position, the marginal gingival tissue is at a parallel or
symmetrical level on both central incisors, a lower location on the lateral incisors and
slightly higher and ideally symmetrical on the canine.

. Class /I

33
Average location of the gingival and co-ordinate tooth position in Class II or pseudo
Class II, exhibits a highei location of gingival height on lateral incisors relative to central
incisors, with a slight overlap of the laterals on the centrals
3.3 Gingival symmetry
Gingival symmetry of the central incisors requires special attention. Gingival symmetry
between lateral incisors and canines is not mandatory, and unilateral display of free
gingival margin of a ateral incisor or a canine in various smile positions is also
esthetically acceptable.

Fig.42

Fig.43

4. PHYSICAL
Fig.44
34
COMPONENTS (ILLUSIONS)
The art of creating illusions consists of changing perception to cause an object to appear
different from what it actually is. The use of optical concepts to create optical illusions
may be the best way to solve or hide an esthetically difficult situation. The control of the
phenomenon of light reflection and colour contrast will provide us with means of creating
illusions and thereby, re-establish proportions.
"The cardinal rule is that everything is relative to something else." (Fig.45)
The process of perception is an organization of sensory data (sight, hearing, taste and
smell stimuli), which are brought to the intellect where an answer is developed in
combination with results from previous experiences or beliefs that are unconsciously
interpreted. Visual perception is a prerequisite for esthetic appreciation in the same
fashion that visual examination is also a routine in normal clinical investigations.
Visual perception is: (Fig.46)
• Increased by increasing contrast
• Increased by increasing light reflection
• Decreased by increasing light deflection
4.1 Principles of illusions

• Principle of illumination: states that shadows create depth and light creates
prominences.
Unidirectional, artificial light throws no shadows, therefore displays only length and
width, whereas multidirectional light throws shadows adding a third dimension of
depth.
• Principle of lines: states that vertical lines accent length and horizontal lines
accent width.
4.2 Law of the face
Suggests alteration of the silhouette form of the tooth, which in turn changes light
reflection and creates a perception of a different facial form.
The "face" of a tooth is that area on the facial surface of both anterior and posterior teeth
that is bound by the transitional line angles, which mark the transition from the facial to
the mesial, distal, cervical and the incisal surfaces. The "apparent face" is that portion of
the face that is visible to the observer from any single view. The law of the face implies
35
making dissimilar teeth appear similar by making the apparent faces equal, by creating
similar transitional line angles. When the line angles cannot be repositioned on a
restoration, the portion of the tooth can be stained dark, promoting the effect that the
tooth is receding.
4.3 Altering the perception of the maxillary central incisor
These optical principles should be applied by means of tooth contouring and colour
manipulation.
• Initial situation (Fig.47,48&49)
3 labial prominences
Line angles
Cervical convexity
Vertical and horizontal lines or ridges
• Narrowing illusion (Fig.50&51)
Tooth contour modification:
Displace line angles mesially
Increase convexity of central prominences mesiodistally
Increase length of central prominence moderately
Increase facial embrassures
Highlight texture and gloss with vertical lines and ridges
Displace proximal contacts palatally
Rotate distal aspect lingually
Tooth colour modification:
Increase dark staining of interproximal areas
Applications:
To close diastemas
To decrease large pontic space
To control tooth proportions
• Widening illusion(Fig.52&53)
Tooth contour modification:
Displace line angles laterally
Decrease curvature of central prominence rnesiodistally / flatten facial outline

36
Decrease facial embrassures
Highligllt texture and gloss with horizontal lines and ridges
Rotate distal aspect labially; overlap
Tooth colour modification:
Decrease staining of interproximal areas
Applications:
To correct crowding (limited result)
To increase narrow pontic space
To improve tooth proportions
To correct elongated crowns after periodontal or implant surgery
• Shortening illusion (Fig.54&55)
Tooth contour modification
Adjust incisal incline lingually
Emphasize and displace cervical convexity coronally
Decrease length of central prominence
Flatten middle 1/3rd to broaden surface of light reflection
Highlight texture and gloss with horizontal lines and ridges
Tooth colour modification
Darken gingival 1/3rd
Decrease interproximal staining
Applications
Asymmetry of maxillary incisors
Long pontics
To control tooth proportions
To correct elongated clinical crowns after periodontal or implant surgery
• Lengthening illusion (Fig.56)
Tooth contour modification
Flatten and displace cervical convexity apically
Flatten labial surface gingivoincisally
Increase length of central prominence
Round labial surface mesiodistally

37
 Highlight texture and gloss with vertical lines and ridges
Tooth colour modification
Lighten gingival 1/3rd
Increase interproximal staining
Applications
Asymmetry of maxillary incisors
To correct a short maxillary central incisor that cannot be lengthened surgically

4.4 Altering perception of tooth by making changes in adjacent tooth/teeth

38
 Fig.45 Fig.46

Fig.47 Fig.48

Fig.49 Fig.50
39
 Fig.51 Fig.53
Fig.52
COLOUR
Perceiving and
analyzing colour is a Fig.54
Fig.55
skill that can be taught and one that can be improved
with practice. Colour cannot be perceived without light,
which is a form of electromagnetic energy visible to the
eye. The visible spectrum of light lies in a narrow band
of 380m to 760nm.

1. DIMENSIONS OF COLOUR
Fig.56
Colour has 3 dimensions:
HUE CHROMA VALUE
• Hue: is the quality of sensation according to which an observer is aware of the
varying wavelengths of radiant energy. In Munsell's words, "it is the quality by
which we distinguish 1 colour family from another." The order of the physical hue
is VIBGYOR, but within the visible spectrum, there is no clear demarcation
between discrete lines. The primary source of natural tooth colour is dentine and
its hue is either in the yellow or yellow-red range.
In the Vita shade guide there are 4 hues
'A" for reddish brown
'B" for reddish yellow

40
 'C" for' grayish
'D" for reddish-grey
• Chroma: is the dimension of colour that defines the intensity or concentration of
the hue. in Munsell's words, "it is that quality by which we distinguish a strong
colour from a weaker one." In teeth, it is dictated by the dentine and influenced by
the translucency and thickness of enamel. Pale colours have low chroma whereas
intense colours have high chroma. E.g. in the hue "A" of the Vita shade guide, A 1
has the lowest chroma, whereas A4 has the highest. Canines usually have higher
chroma than incisors in the same mouth.
• Value: is the relative blackness or whiteness of colour. On a scale of black to
white, white has" high value", black has "low value" and midway between the
black and white is medium grey Value is the only dimension of colour that can
exist by itself. Value differences are more noticeable and thus have more relative
significance in a dental restoration than hue or chroma. In the hue "A" of the Vita
shade guide A 1 is the brightest while A4 is the darkest.
Evaluating dimensional differences
Colour matching authorities state that hue differences are the easiest to detect and
value differences the most difficult. In the evaluation of value and chroma differences,
education and training are needed. Confusing value (degree of brightness) differences
with chroma (colour purity or saturation) differences is common. To test value
differences, squinting is recommended. This eliminates detail and reduces the field of
vision to a more achromatic (colourless) condition, making it easier to concentrate on
value differences. When two objects being compared look more different during
squinting than with normal viewing, a value difference is certain. Squinting is not a
panacea for matching problems, but it provides a starting point that can be applied to
clinical practice.
2. PROPERTIES OF COLOUR
• Opacity and translucency: (Fig.58&59) As light strikes a surface it is either
totally reftected (opaque), totally transmitted (transparent) or a combination of
both (translucent). Translucent objects transmit part of the incident light and
scatter the rest. Translucency decreases with increased scattering within the

41
 material. It is the three-dimensional spatial representation of hue. Highly
translucent teeth tend to be lower in value, while opaque teeth have higher value.
• Metamerism: The change in coloLlr perception of two objects under different
lights is called metamerism. Two objects with identical spectral distribution
curves will always match regardless of the illumination. When attempting to
create different materials with the same colour, however, identical spectral
distribution is difficult to achieve, resulting in metamerism. Such objects appear
to be of the same colour under some lighting conditions, but not others. Tooth
structure, porcelain and other tooth coloured restoration materials have different
spectral distribution curves. They should, therefore, be tested under three light
sources: daylight cool white fluorescent light and an incandescent lamp.
• Fluorescence: The emission of light by an object at a different wavelength from
that of the incident light is called fluorescence. The emission stops immediately
on the removal of the incident light. Teeth fluoresce with a stimulus in the blue
spectrum of colour i.e. 340nm to 410nm.
• Gloss: Gloss is an optical property that produces a lustrous surface appearance,
thus reducing the effect of colour difference and increasing the brilliance.

Fig.58
Fig.59
42
3. PERCEPTION OF COLOUR
Perceiving and analyzing colour is a skill that can be taught and one that can be improved
with practice. Colour perception and shade selection are affected by several variables and
involve many physical, physiological and psychological aspects.
• Light source: The lighting environment makes a significant difference in the
perception of colour. If light of a certain wavelength is absent or deficient in the
source of light, it cannot be reflected to the observer even though the object might
be capable of reflecting such light. Therefore, it is essential to illuminate an object
with full spectral lighting in order to assess its colour correctly. The dental
operatory maybe illuminated with a combination of natural sunlight and artificial
light. It is imperative to establish similar lighting environment in the dental
operatory and the technician's laboratory so that there is a constant colour purity
of white light. Daylight, though ideal, cannot be routinely used as it varies with
time, atmospheric conditions and season.
The ideal colour temperature for shade selection should be 5500K to 6500K
Colour rendering index (CRI): The point where all hues are perfectly balanced is
given a CRI of 100. For dental shade matching a CRI of 90 or above is recommended.
Commonly used fluorescent tube lights emit colour with a green tint that can distort
colour perception, therefore colour corrected operating lights and fluorescent tubes
should be used.
Contrast ratio: The ratio between the task light and the ambient light is known as
contrast ratio and should be between 3: 1 and 10: 1.
The dental operatory should always be evenly and adequately illuminated with neutral
qrey or pastel blue walls. Ceilings must have a Munsell value of 9 for maximum
reflectance. Walls should have a Munsell value of at least 7 and a chroma of less than
4.
• The object: The quality of the colour of an object depends upon its ability to
absorb, reflect or transmit the light energy falling on it. The surrounding
environment greatly influences the colour of the object.
• The observer (colour vision) : The eye receives visual images through the

43
 reception of light, which it directs to receptor cells, rods and cones, which convert
this information and transmit it to the brain for interpretation.
Cones are packed tightly in the foveal region, which is the center of most acute
vision, but rods are found away from the fovea and increase in numbers towards the
periphery of the retina.
There are three types of cones, each containing a photosensitive pigment with a range
of sensitivity to which it will respond. The pigments respond selectively to the
additive primary colours of blue (445nm), green (535nm) and red (570nm), so the
human visual system is able to receive colour through the additive colour system
because the pigments convert light to colour sensation.
On the other hand, achromatic vision is mediated by the rods. Value can be best
appraised by "looking off" the fovea and squinting. When the eyes are narrowed, the
light admitted is diminished and the focus becomes less acute. This favours rod
function and the judgments of value are enhanced.
Defective colour vision
Normal colour is called trichromatic vision as it is derived from three photosensitive
pigments. Total colour blindness (monochromatism) is extremely rare; other less serious
defects in colour vision are sex-linked and affect about 8% of the male population. The
most common defects occur when the person can see all three primary colours, but has a
weakness or confusion in some area, usually the red or green area. There are also types of
defects where the person can see only two of the primary colours.
It is clear that colour defects should be identified in dentists so that compensatory steps
can be taken.
Neqative after-imaqe
The ability to perceive the correct hue is progressively diminished with time if one stares
long enough. As light of a particular wavelength strikes the cones sensitive to the
stimulus, the photosensitive pigments involved are depleted at a rate faster than
regeneration can occur, making the eye less sensitive to the hue range of that stimulus.
The accuracy of shade judgments becomes rapidly less reliable through this phenomenon
termed "hue adaptation". Along with the waning ability to perceive a given hue, the eye
becomes more responsive to the complementary hues of the adapted range. E.g. intense

44
red lipstick can make teeth appear greenish by reducing red perception.
To overcome the problem in clinical situations, comparisons in shade selection should
not exceed 5 seconds duration. The gaze should then be diverted to a card of a medium
blue colour to adapt vision to blue and sensitize it to the yellow of the teeth. The eye can
then continue to be an active receptor
4. SHADE SELECTION
Shade selection is both a visual and a cerebral process. For optimum results, it
must follow a logical sequence:
4.1 Basic shade
4.2 Basic shade variations
4.3 Enamel shade, translucency and location
4.4 Special effects
4.1 Basic shade
The basic tooth shade (or hue) must be evaluated by matching the center of the
natural tooth with the closest approximating shade tab. The first impression is the most
important because spontaneity gives the best results. When in doubt, the two closest
matching shade tabs should be compared directly under the natural tooth
• Shades in the "A" group are the closest yellow hues to red and are frequently
encountered in young individuals.
• Shades in the "B" group are closer to pure yellow, located on one extreme of the
natural tooth colour space and represent only a fraction of natural hues. A false
perception of yellow also occurs when the natural tooth is observed in contrast to
a pink or red background.
• Shades in the "C" group may be considered a subgroup of the "B" family because
they have a somewhat comparable hue but at a lower value. Therefore, they are
frequently encountered in middle aged and older individuals or in patients with
tetracycline-stained teeth
• Shades in the "D" group are rarely encountered but maybe considered a sub group
of the "A" family because they have a somewhat comparable hue with a lower
value.
Note: shades in the "C" or "D" group represent only isolated examples of lower value of

45
a given hue of the "B" or "A" group, and as such do not automatically provide the
expected value when a n "A" or ''8'' tab of a lower value is desired.
4.2 Basic shade variations
After the basic hue is determined, the next step is to detect its variations according to
the location on the tooth, the addition of the orange to the basic hue, or the
incompatibility with standard shade tabs.
• Orange modification: various studies indicate that natural tooth colour falls in
either the yellow or orange colour space. The orange tonality is either expressed in
the body of the tooth or is confined at the cervical aspect.

• Variation according to location: Nakagawa et al reported four broad categories of

shade pattern according to their location on the tooth.
Incisal third: The most frequent variation was observed at the incisal third.
Characteristics of the basic hue at the incisal third should be evaluated in terms of
mamelon colour, abrasion colour in case of attrition, or continuity with the basic
shade if there is no enamel or translucent demarcation. Mamelon shape tends to
blunt and widen with aging and takes a whitish-orange hue.

Uniform: The next most frequent category was nearly uniform shade distribution,
resulting in a monochromatic appearance.
Cervical third: Cervical variations may either correspond to the cervical aspect of
the shade tab or tab of another shade guide, or be perceived as more saturated,
more orange, or lighter in comparison.
Middle aspect: the clinician should determine whether the basic shade is uniform
or whether shade variations occur on the body of the tooth.
4.3 Enamel shade, translucency and location:
Once the hue and its variations are determined the quality and location of the
enamel overlay must be separately evaluated. Because it may range from whitish opaque
to very transparent, it also affects the value of the tooth. Teeth in young patients may
have white shades with high value because of the dense and highly reflective enamel.
Teeth in middle aged and elderly patients may appear duller or more orange because of
the translucent or almost transparent enamel. Between these two extremes, enamel

46
assumes a semi-translucent quality.

Enamel of the natural tooth should be analyzed in terms of value and translucency. This
evaluation may either be made with conventional shade tabs, separate enamel tabs
available from the manufacture or with customized fired enamel samples.
For maximum individuality in esthetic reconstruction, the opacity of the enamel overlay
should increase when proceeding from the central incisor to the canine.
Translucent enamel zones may stand out or less distinctly from the basic tooth colour and
have been classified by Sekine et al into three groups
Type A : Translucent layer cannot be discerned and is distributed over the entire aspect of
the tooth.
Type B : Translucent layer is present at the incisal aspect only.

Type C: Translucent layer is present at both the proximal and incisal aspects.
Additionally, a halo at the incisal edge is produced by total reflection of light within the
confines of the incisal edge, resulting in an opaque outline.
Opalescence
Is an important component of the perceived enamel colour. It is caused by the
scattering of light between two phases, namely hydroxyapatite crystals and the enamel
ground substance, that have different refractive indices. These crystals, acting as
microparticles smaller than the wavelength of light, scatter incident light. As a result,
under incident light, longer wavelengths (orange and red) of light are selectively
transmitted through the tooth, whereas shorter wavelengths are reflected on the enamel
surface, producing the subtle bluish gleam characteristic of opalescence.
4.4 Special effects through staining
4.4a staining to alter shade
Objective Colour of stain
Incisal edge
Blue, blue-violet, blue-green
To intensify translucency
(complementary
hue lowers value and reduces
chroma)
Orange, orange-brown, brown
(complementary

47
 hues adjacent to one another, enhance
each
other. Also help to create third
dimension)
Orange, red, yellow, grey, white (add
To decrease translucency
white
sparingly)
Incisal-gingival blend
To increase incisal translucency Violet (for yellow body shade)
Blue (for brownish-orange body
shade)

Control chroma
Gingival third Yellow or orange
Red, yellow, blue (all three primary
Increase chroma
colours in
equal amounts with emphasis on hue
to be
strengthened)
Clear (use sparingly)
Decrease chroma

Control value
Complimentary hue of desired shade
Decrease value (e.g.: yellow shade)
(e.g.: violet)
Increase value Not possible

4.4b Staining to add characterization:

Effect sought Colour of stain
Random discolourations & White, orange, brown, blue, yellow
Labial mottling

Fissures and apertures

Orange to brown (lighter yellow-
Sulci and proximal apertures
orange in
young people; deeper burnt orange as
aging
progresses)

48
Worn enamel and exposed dentin Orange to brown
Exposed dentin of smoker Orange-brown or brown

Incisal wear/erosion Yellow-brown

Grey (distal), white (mesial), yellow,

Enamel cracks (young patients)
Check-lines
Grooves and pits (occlusal of
posteriors and
lingual of anteriors)
Decalcification/hypocalcification
Cervical stain/gingival erosion
black (for
shadow effect)
Brown, black, yellow, orange
Brown, black, orange, blue
Opaque white, yellow, brown, grey
Brown, yellow, grey, lime green

Existing silicate or composite

Stained outline Orange, brown, grey (should fade out
irregularly)
Restoration itself Opaque white, grey, yellow, brown

Amalgam stain Grey, black, blue

Guidelines for shade selection

• Any colour modification process like bleaching or micro abrasion should precede
colour selection after ensuring colour stabilization.
• Stains and deposits must be cleaned off the tooth, and the tooth must be kept wet
throughout shade determination.

• Shade evaluation must not be made after an aesthesia is administered, after tooth
preparation is completed or after a strenuous appointment.
• Value, translucency, chroma and hue should be matched in
that order.

• When in doubt, always select higher value and lower chroma, since it is easy to
lower the value and increase the chroma.

5. COMMUNICATING COLOUR

49
 If the principles of colour are understood by both the technician and the dentist,
communicating colour is much simpler.
The various methods of communicating colour are:
• Modern shade guides:
When a tooth closely approximates a specific shade selection tab, but has
characterizations or deviations, aluminium oxide particles or emery discs are used to
remove the shade tab glaze and colourants may be applied, removed or modified until
the proper effect is achieved.
• Custom shade guides:
According to Vryonis, approximately 85% shades can be matched with existing shade
guides. The remaining 15%, however, fall outside of the hue of standard tabs and
require fabrication of a custom tab. A custom shade guide, especially one having an
expanded shade range can be very helpful. Unlike most shade guides, a custom shade
guide is made of the same material as the final restoration, thus decreasing
metamerism.

• Colour sketches:
A set of coloured pencils or fine-line markers can be very helpful in sketching colour
zones and variations in translucency. They require a narrative describing the meaning
of each part of the drawing.
• Photographs:
It is one of the best methods of communicating colour. It gives a vivid description of
the relative translucency, opacity, colour zones and incisal variations. The truest
colour will come from colour transparencies (slides). To be more effective the desired
shade tab should be held adjacent to the tooth and photographed. The intraoral camera
is also a great help with shade communication.

ESTHETIC DIAGNOSIS AND TREATMENT PLANNING

A meticulous esthetic diagnosis followed by a well-defined treatment plan is the

foundation of successful esthetic dental treatment. The definitive treatment plan should

50
address the treatment periods, expenses, treatment sequencing and all aspects related to
the function and maintenance of the anticipated result.
Most esthetically motivated patients are eager to begin corrective treatment.
Nevertheless, their enthusiasm and, at times, self-diagnosis should not influence the
dentist's esthetic diagnosis. It is essential that the patient make an informed decision, after
receiving a thorough explanation of his/her condition and the ramifications of treatment,
including the advantages and disadvantages of each treatment alternative.
1. PATIENT HISTORY
Information should cover aspects of:
• Medical history: allergies, systemic disorders, previous surgeries etc.
• Dental history: past dental experiences, apprehensions, expectations etc.
• Personal and Social history
2. CLINICAL EXAMINATION
A clinical examination involves a thorough evaluation of facial and
temperomandibular components and assessment of occlusal relationship, periodontal
attachment, teeth and intra-oral soft tissues.
• Facial components Face form, symmetry along the midline, relationships of
various parts of the face, position of lips and chin from frontal as well as lateral
aspect, relationship of horizontal and vertical references of face with respect to
teeth and gums.
• TMJ: Palpated and auscultated for clicking, crepitus, hypermobility and
deviation.
• Occlusal relationships' Occlusal pattern, type, contacts, disclusions and path
during mandibular movements
• Periodontal attachments: Plaque, calculus, gingival inflammation, amount of
attached gingiva, recessions, hyperplasia etc.
• Teeth: Caries, existing restorations, discolourations, wear facets, erosions etc.
3. ESTHETIC EVALUATION
The following analysis chart covers the facial, dentofacial, dental and functional
analysis. In case any abnormalities found in the soft tissues, hard tissues, TMJ and
occlusal pattern, a thorough evaluation is recommended before esthetic treatment

51
planning.
Visual Analysis Chart
Facial
--
Face forms Square, round, oval, pear, tapered
Frontal perspective Nasio-Iabial groove Exaggerated
Mento-labial groove Normal
------
Vertical height Adequate
More
Less
Lips Competent
Incompetent
Full

Dento-facial
Inter-pupillary line Incisal plane Parallel/not parallel
Gingival
- Parallel/not parallel
plane
Maxill
Canting / not canting
a
Lengt maxillar incisor
Upper lip line of <1mm
h y s
visible at rest 1 - 4mm
>4mm
Vertic positio gingiv
of Low
al n al
margins during
Average
smile
High
positio
Lower lip line Bucco-lingual of Touching
n
maxillary
Not touching
incisors
Slightly covered
Curvature of incisal
Convex
plane
Straight
Concave/reverse
Facial midline Dental Center

52
 midline
Right of center
Dental Left of center
Teeth Axis of dental
Decayed, Straight
deficient restorations
Missing
midline
Malformed Oblique
Malaligned (overlapped/flared)
Moderate smile Gingival <3mm
Violation of width to length ratio or golden
display
proportion
>3mm
Fractured, chipped, attrition, abrasion
Gingival - Esthetic
Discoloured
Diastema
patterns
Pathological migration Unesthetic
Supra-eruption
Vestibular Less (expanded arch)
Gingiva Inflammation
space
Recession, black triangles
More (contracted arch)
Hyperplasia
Horizontal tooth 6/8/10/12 teeth
Altered gingival display
Pigmentation
display
Frenal attachment

Function
Temperomandibular joint Joint clicking, crepitus, hyper-mobility, dislocation
Deviation while opening and closing, jerky
Mandibular joint
movements
Occlusion Antero-posterior plane Molar relationships
Canine relationships
Incisal relationships
Vertical plane Open bite
Deep bite
Edge to edge
Transverse plane Rotation
Cross-bite

Phonetics
Adequate/defic
'S' sound Anterior speaking space
ient
Posterior speaking space Adequate/defic

53
 ient
Incisa maxillar Touche vermilio
'P' or 'V' sound edge of inner
l y s n
inciso
border
r
T ouches outer border of
lower
lip
Does not touch lower lip
Incisal
'M' sound <1mm
display
1-4mm
>4mm

4. SPACE ANALYSIS
Space analysis helps the dentist to gauge the amount of space available during the
treatment planning stage. The concept is to measure the widths of all the teeth and
compare it with the space present in the arch. The normal length to width ratios of teeth
should be borne in mind and the law of golden proportions should be closely followed to
prevent violation of natural proportions. Thus, space maintenance for restorations in
terms of illusions, rotations, overlaps etc. can be carried out as planned.

5. PROFILE ANALYSIS
Patients with impaired dentofacial esthetics resulting from underlying skeletal problems
can be identified wit the use of profile analysis.
The patient’s profile can be:
• Straiqht / Orthoqnathic
• Convex / Retroqnathic :
Due to: - prognathic maxilla - normal mandible
- Normal maxilla - retrognathic mandible
Prognathic maxilla - retrognathic mandible
Features: - normal/increased / decreased lower facial height
- Lower lip trap, depending on the position of lower anteriors
Deep mentolabial groove

54
 • Concave / Prognathic:
Due to : retrognathic maxilla - normal mandible
- Normal maxilla - prognathic mandible
Retrognathic maxilla - prognathic mandible
Features: increase / decrease in lower facial height
- Maybe associated with habitual or pseudo Angle's Class III occlusal
relationship.

6. DIAGNOSTIC AIDS
Study casts
Accurate study casts help give necessary inputs regarding intra-arch relationships like
arch-length versus tooth size discrepancies; alignments; angulations and inter-arch
relationships like Angle's classification, overbite, overjet, plane of occlusion etc. They
also reveal functional relationships involving centric and protrusive interferences,
working sidebalancing side interferences, wear facets etc.
Radiographs
IOPA and bitewing radiographs are used to detect interproximal caries, bone levels and
quality, periapical pathologies etc. Panoramic radiographs help to analyze pathologic
lesions, impacted teeth, teeth angulations etc. Radiovisuography has become extremely
popular as it cuts down radiation by 80-90% and multiple different angle views cali be
taken.
Intraoral camera
Is a powerful communication tool as it provides instant visualization of the patient's teeth.
It has the ability to easily transilluminate and photographically record hidden microcracks
that could alter the treatment plan.
Extraoral camera
Can record the whole oral frame including the smile window along with the smile line, lip
lines, negative spaces, midline shifts, gingival asymmetries etc. It plays an important role
in records for diagnosis and treatment planning, self-analysis, laboratory communication,
patient management, marketing, medicolegal purposes and scientific documentation.
Magnification loupes

55
Help in accurate, detailed observation of tooth characteristics. Magnifying lenses of 2.5
diopter or greater are extremely valuable diagnostic tools.
T-scan occlusal analysis
Is a computerized system that uses sensor technol.ogy to identify the location, timing and
relative force of occlusal contacts.
Periodontal charting
No part of the esthetic examination is more important than ascertaining the condition of
the patient's supporting bone structure. The periodontal ligament of each tooth is
thoroughly probed in six locations and charted. This can be done with either a traditional
periodontal probe or an electronic device where the data is recorded electronically using a
voiceactivated system.
Computer imaging
Offers an unparalled method of visualizing your intended esthetic correction and the
effect it can have on the face. It helps patients to make suggestions and is a brilliant
motivational tool.
7. INITIAL THERAPY
Initial therapy is required before esthetic treatment planning to arrest active pathoses,
bring adequate health to the dentition or give the patient relief from pain.
 Periodontal therapy:
control of all periodontal inflammation through scaling and root planning
replacement of overhanging restorations and crowns with improper margins and
contact areas
extraction of periodontally hopeless and non-strategic teeth

relief from "trauma from occlusion" by conservative selective grinding and use of
occlusal splints.
 Pulpal therapy:
endodontic procedures for asymptomatic and symptomatic teeth with necrotic pulps.
 TMJ disorders:
orthopedic appliance therapy for conservative management of TMJ disorders.
8. ESTHETIC TREATMENT PLANNING AND SEQUENCING
The definitive treatment plan should address the treatment period, expenses, treatment

56
sequencing and all aspects related to the function and maintenance of the anticipated
result.

Several treatment plans can be proposed to the patient for esthetic correction. A problem
list is made related to the dentofacial problems enlisting individual solutions for
individual problems and the impact on the overall outcome.
A completed "Smile Analysis Form" can be discussed after the patient has reviewed the
radiographs with the dentist, to understand the patient's attitude and expectations.
S.No. Teeth Yes No
In a slight smile, with teeth parted. do the tips of your
1.
teeth show?
Are your two upper front teeth slightly longer than the
2
adjacent teeth?
3 Are your two upper front teeth too long?
1---.
4. Are your two upper front teeth too wide?
5. Are your upper six front teeth even in length?
6. Do you have space between your front teeth?
7. Do your front teeth protrude or stick out?
8. Are your front teeth crowding or overlapping?
9. When you smile broadly, are your teeth all one colour?
10. Do your teeth have white or brownish stains?
If your front teeth contain tooth coloured fillings, do
11.
they mater. the
shade of your teeth?
12. Is one of your front teeth darker than the others?
13. Are your lower six front teeth straight?
14. Are your lower six front teeth even in appearance?
In a full smile, the back teeth normally show. Are your
15.
back teeth free
of stains and discolourations from unsightly
restorations?
Do the necks of your teeth indicate erosion, a ditched-
16.
in "V", that
either can be seen or felt with your fingernails?
When you smile broadly, does your top lip rise above
17.
the necks of

57
 your teeth so that your gums show?
Do your restorations - fillings, laminated and crowns -
18.
look natural?
Gums
Are your gums pink and "knife-edged", or are they red
19.
and swollen?
20. Have your gums receded from the necks of the teeth?
Does the curvature of your gums around each tooth
21.
create a half-
moon shape?
Breath
Is your mouth free from decay or gum diseases that can
22.
cause bad
breath?

Treatment sequencing is an integral part of treatment planning. It is a phase-wise

distribution of treatment procedures, which will be programmed or charted considering
periods of healing, patient convenience and interdisciplinary treatment modalities. The
treatment sequence may change during the treatment, as some conditions may need to be
reviewed or certain additional procedures may become necessary to get the desired result.

9. FINAL CASE PRESENTATION

There are three basic methods to help patients visualize your suggested solutions:
 Mock-up with soft tooth coloured wax or composite
resin

Direct composite resin placement along with the use of intra oral markers can be
beneficial in simple situations, since they provide a visual three dimensional meanS
for the patient to see the final result prior to committing to treatment. The functional
movements in the mouth can also be checked at this time to determine any potential
in occlusal obstructions or difficulties.
 Diagnostic wax ups on study casts

Probably the best method and one that has stood the rest of time is to prepare a
diagnostic wax-ups and evaluate with the patient. This wax-up itself can be evaluated

58
 by the patient directly on the diagnostic casts of the articulator and also intraorally
with the use of acrylic overlays and acetate matrices.
Computer imaging

Digital imaging takes advantage of contemporary technology. In a particular case

esthetic enhancement with a change of arrangement, form, shape and color can be
demonstrated quickly. Thus it can be used as a quick reference which can guide future
artistic creations.

PHYSIOLOGICAL/BIOLOGICAL CONSIDERATIONS

How good is a new smile if it doesn't last? However pleasing a dental restoration may
appear, if it is destructive to the biologic system, it is "ugly". Form and function are
intimately intertwined. The anterior region of the mouth presents a double challenge
because it deals not only with the vital anterior guidance system, but also the most
predominant area of esthetics. Both objectives must be-satisfied.
The safest sequence of treating a mouth to bioesthetic function is as follows:
 Good diagnosis and treatment planning Patient education
 Treating the periodontium
 Stabilizing the craniomandibular relations in centric relation
 Restoring anterior teeth to bioesthetic function Restoring posterior teeth to natural
physiologic function
 Regular post-treatment maintenance

1. OCCLUSAL CONSIDERATIONS
Tooth morphology is totally genetic and not specific to race or gender. Nature
produces sharp tooth morphology on both anterior and posterior tooth surfaces, therefore
it is necessary to have unworn crown morphology for good esthetics as well as function.
Natural crown morphology of both anterior and posterior teeth develops early in life and
is complete in every detail prior to tooth eruption into the oral cavity. However, the other
components of the gnathostomatic system, including the joints, ligaments, muscles,

59
maxilla, mandible and other cranial facial bones, continue to change significantly long
after the occlusal morphology of the teeth is complete. These changing components, such
as the temperomandibular joints, maxilla and mandible, are predetermined by genetics.
The skeletal components, however, are subject to environmental modification by factors
such as abnormal posturing of the mandible due to poor occlusion, face sleeping,
abnormal swallowing, thumb-sucking and other abnormal habits.
Natural and restored maxillary and mandibular teeth should have optimal functional
contact relationship resulting in the even distribution of load in static and dynamic
positions leading to minimal trauma of teeth and supporting structures.
1.1 Forces on the dentition
The peri-oral musculature and the tongue exert a constant force on the teeth. In
full occlusion, the lower lip and upper lip rest against the labial surface of the maxillary
incisors. The lower lip helps retain the maxillary teeth against the mandibular anterior
teeth while the tongue holds the mandibular incisors against the maxillary incisors in a
state of equilibrium, referred to as the
"Neutral Zone". (Fig.60)This lip-tooth-tongue relationship helps produce a negative
pressure seal during mastication and swallowing as well as stabilization of teeth
positions.
The direction and dissipation of load makes a difference in the forces exerted on
the anchored root and the surrounding bone. The process of directing occlusal forces
through the long axis of the tooth is called "Axial loading". Vertical load causes less
stress compared to lateral load. A thorough examination reveals that canines are best
suited to accept horizontal forces during eccentric movements as they have the best
crown-root ratio and dense compact bone around the roots.
The maximum biting force is in the range of 30-50 psi for the incisors, 47-100 psi for the
canines and 127-250 psi for the molars.
1.2 Mandibular movements:
The mandibular movements are influenced by the anatomy of the mandibular fossae
and the condylar head, shape of the articular eminences, musculature as well as the
attachment and movement of the articular discs.
 Functional movements: (Fig.61) The functional movements occur during the

60
 functional activity of the mandible. They occur in all three planes. When the
mandibular movements in all three planes i.e. sagittal, horizontal and vertical are
combined, we get a three-dimensional "Envelope of Motion". The actual size of
functional mandibular movement in the horizontal plane takes place within a
small diamond shaped area, only 3mm to the right, left and forward.
 Parafunctional movements.' are identified as a cause for occlusal wear and
excessive forces. They can be related to local factors like malocclusion, to
systemic factors like cerebral palsy, epilepsy and can also be stress and
occupation related. Bruxism, clenching and parafunctional tongue-thrust are
important parafunctions which the dentist should consider during the treatment
planning stage.
1.3 Types of articulation
 Balanced occlusion: this occlusion has all teeth contacting in all excursions. It is
primary a denture occlusion. Naturally occurring examples are cases of advanced
attrition.
 Mutually protected/canine-guided occlusion: when the mandible is moved in a
right or left laterotrusive excursion, only the maxillary and mandibular canines
contact and efficiently dissipate the horizontal forces while disoccluding the
posterior teeth. Canines are best suited for this as they have large roots, dense
surrounding bone and trigger fewer muscles during eccentric activity, decreasing
forces to the dentition and the TMJ.
 Group function: there are contacts between the maxillary and mandibular teeth on
the working side in eccentric movements. The non-working side completely
disoccludes. This is the most favourable alternative to canine guidance in case the
canine is unavailable or periodontally compromised. The most desirable group
function consists of the canine, premolars, and sometimes, the mesiobuccal cusp
of the first molar.
1.4 Centric relation (Fig.62)
Is defined as the completely retruded position of the mandible with the condyles
in their most superior anterior position at any vertical rotational position of the mandible.
CR has been found clinically to be the best location for maximum intercuspation of teeth.

61
In good occlusion, all teeth in the mouth (anteriors and posteriors) make simultaneous
contacts. Anterior teeth should never contact harder than the posteriors or fremitus may
be produced with possible endodontic and periodontal trauma and/or interproximal
separation of teeth. Normally, occlusal contacts on the anterior teeth in CR are not broad,
but rather two or three spots per tooth on the incisors and one on each canine. The total
contact area has been estimated to be about 4mm for the entire mouth, including all of the
anterior and the posterior teeth.
Stabilization of the craniomandibular relation in CR is important to the comfort, function
and longevity of dental restorations. .
1.5 Anterior overbite (Fig.63)
The maxillary anterior teeth are normally positioned labial to the mandinbular
anterior teeth. Both maxillary and mandibular anterior teeth are inclined in a labial
direction ranging 12 to 28 degrees from a vertical reference line.
In well-related teeth, the vertical overbite of the maxillary central incisors ranges from 4-
5mm when the teeth are in full occlusion. The horizontal overbite of the maxillary
incisors is 2-3mm in full occlusion
Variations can result from different developmental and growth patterns.
 When a person has an underdeveloped mandible (class II molar relationship), the
mandibular anterior teeth often contact at the gingival third of the lingual surfaces
of the maxillary teeth (deep overbite).

 In persons in whom there may be pronounced mandibular growth, the mandibular

anterior teeth are often positioned forward and contact with the incisal edges of
the maxillary anterior teeth (molar class III relationship). This termed in edge-to-
edge relationship.
 Another anterior tooth relationship is one that actually has a negative vertical
overlap. In other words, with the posterior teeth in maximum intercuspation the
opposing anterior teeth do not overlap or even contact each other. This anterior
relationship is termed an anterior open-bite. In a person with an anterior open-bite
there may be no anterior tooth contacts during mandibular movement
(Fig.64,65&66)
1.6 Anterior guidance

62
 Is the dynamic relationship of the lower anterior teeth against the upper anterior
teeth through all ranges of function. It literally sets the limits of movement of the front
end of the mandible.
Anterior relationships must be determined with extreme preciseness because
along with the discomfort and look of artificiality, improperly restored anterior teeth may
contribute to the destruction of the entire dentition. When their position allows it,
anteriors should be made to form a very stable stop for the front of the mandible, thereby
limiting its closing motion.
Anterior guidance is of two types:
 Incisal guidance (in protrusive-retrusive movements) : its primary importance is
for proper incising as well as rest positions and speaking functions.
 Canine guidance (in mediotrusive lateral movements) : the primary importance of
the canine guidance is to help prevent lateral eccentric posterior tooth
interferences and allow the condyles to move uninhibitedly along their border
pathways in the fossae as well as to guide jaw closures more vertically to load the
posterior teeth in their long axis.
2. PERIODONTAL CONSIDERATIONS
A healthy periodontal environment with sufficient tissue volume to fill the
interproximal spaces is an essential element for ideal anterior esthetics. The tooth shape,
incisogingival length, mesiodistal width and the contact areas guide the gingival position
in natural dentition.
2.1 Biologic width (Fig.67)
Gargiulo et al demonstrated in human autopsy specimens, a proportional
dimension relationship between the dentogingival junction and the other tooth-supporting
tissues. The mean sulcular depth was O.69mm, the mean length of the junctional
epithelium was O.97mm and the connective fibrous tissue attachment was 1.07mm (with
a range of 1.06-1.08mm). Of these three tissue components, the supracrestal connective
fibrous attachment exhibited the least variability. The combined width of the connective
tissue attachment and the junctional epithelium averaged 2.04mm and has been called the
"Biologic Width".
The importance of not violating this physiologic dimension was suggested by

63
 Ochsenbein and Ross and stressed by other authors. When margin placement impinges on
the biologic width, gingival recession or pocket formation and periodontal disease may
ensue, depending on the thickness of the keratinized gingiva and the underlying bone.
Invasion of the biologic with may result in apical migration of the dentogingival unit with
gingival recession and may be self-limiting. With relatively thicker bone, it may result in
apical migration of the epithelial attachment and pocket formation.

Fig.61

Fig.60 Neutral Zone

Fig.62. Contacts on the anterior teeth in maximum Fig.63

intercuspationshould average about two for
each tooth

64

Fig.64 Fig.66 Fig.65

 Fig.67

BLEACHING

Treatment Time: Usually three to ten treatments, lasting about thirty minutes to an hour
and a half each. It is suggested that three or more professional cleanings per year be given
after treatments are completed to help keep your teeth stain-free.

Patient Maintenance: Thorough brushing after meals is necessary to avoid plaque

accumulation. Smoking, as well as stain-causing foods such as coffee and tea should be
avoided.
Results of Treatment: Deep yellow and brown stains can be considerably reduced,
though teeth may not be returned to natural color.
Average Range of Treatment Life Expectancy: Indefinite, annual touch-ups may be
required, but treatment may last indefinitely.*

65
ADVANTAGES
1. Safe procedure.
2. Painless to adults.
3. No tooth reduction required.
4. No anesthetia necessary.
5. Least expensive of treatment alternatives.

DISADVANTAGES
1. Normal tooth color may not be restored.
2. Bleaching can cause discomfort in children
because of their large pulps
3. Only 75 percent effective in selected cases.
4. Extended treatment time may be necessary.

Treatment summary
COMPOSITE RESIN BONDING
Treatment Time: Usually one or two office visits. The first visit will average about one
hour per tooth. If a second visit is required, it will usually take no more than one hour for
touch-up and final polishing.

Patient Maintenance: To keep the bonded restorations looking their best, you should
have a professional cleaning three or four times a year. The reason for such frequent
cleanings is to remove food stains that accumulate in microscopic spaces on the bonded
surfaces of the teeth. Warn your hygienist not to use an ultrasonic scaler, which can
loosen the bond, or an air abrasive spray, which can dull the polish. These bonded
surfaces are not as strong as your enamel, so try to protect them by eating wisely. For
instance, avoid biting down with front teeth, especially on such foods as ribs, apples, hard
bagels and corn-on-the cob. Expect to have repolishing or repair performed as necessary.
Results of Treatment: On-the-spot masking of stain.

66
Average Range of Treatment Life Expectancy: Average life expectancy is three to
eight years. May need repair or replacement more frequently.
ADVANTAGES
1. Painless.
2. Immediate (one-appointment) results.
3. Little or no tooth reduction.
4. Generally no anesthetia required.
5. Less expensive than porcelain laminates, crowning or "capping".
6. Avoids potential pulp or gum irritation that may occur when reducing tooth for full
crown.
DISADVANTAGES
1. Can chip or stain.
2. If orthodontic treatment is required, it should be completed before bonding.
3. If orthodontic retainers are worn, holding wires should be Teflon-coated (stainless steel
can cause discolorations with some types of bonding materials).
4. Extreme care must be taken to avoid metals (such as hair pins) from coming into
contact with bonding.
5. Bonding has a limited esthetic life expectancy.
6. Certain types of stains (especially dark ones) cannot be covered well with bonding.
7. May involve minor tooth reduction to remove some of the stains.
8. Unless margins are finished perfectly, gum irritation can occur.

TIPS FOR PATIENTS WHO HAVE COMPOSITE RESIN BONDING

1. Do not chew ice.
2. Brush normally. Plaque must be removed daily. Ask your dentist about anti plaque
mouthwashes and toothpastes.
3. Floss teeth at least once daily, but pull floss out horizontally, not vertically.
4. Take multi-vitamins two times daily for one month before and after treatment if gum
tissue is inflamed.
5. Have your teeth cleaned at least three or four times yearly. Be certain that the hygienist
is aware of your bonded tooth or teeth and avoids using ultrasonic scaling or air abrasive

67
on the bonded tooth surfaces.
6. Make sure you are not grinding your teeth at night. If you are, have your dentist con-
struct a bite guard to avoid fracturing the bonding and to minimize damage to your
bonded teeth as well as your temporomandibular joint (TMJ).
7. Don't bite your fingernails. The force can crack the bonding.
8. Don't pick at a newly bonded tooth with your fingernail. You could pull open a
small over-extension and shorten the life of the material. If you feel a rough edge with
your tongue, return to the dentist to have the edge properly refinished.
9. Don't try your new teeth out too soon. Sometimes biting on the other side is not wise
either. Go on a soft diet for the first twenty-four hours. If your bite is not perfect, return to
your dentist to have it adjusted. Never try getting used to a new bite. The bite you are
used to is usually correct.
10. To prevent staining, try to avoid, or keep to a minimum, coffee, tea, soya sauce, colas,
grape juice, blueberries and fresh cherries. And do not smoke.
11. To prevent fracture, avoid directly biting, with front bonded teeth, into the following
foods: ribs, bones (fried chicken, lamb chops, etc.) hard candy, apples, carrots, nuts, hard
rolls, hard bread, bagels or artichokes. Also try to avoid candy, mints or sugar, because
acids produced by sugar can attack the junction between tooth and restoration and cause
stains and premature loss of the bonded restoration.

Treatment summary
LABORATORY-CONSTRUCTED COMPOSITE LAMINATES
Treatment Time: Two visits. Impressions made after tooth preparation. On second visit,
dentist will fit and place laminates.
Patient Maintenance: Same as bonded tooth.
Results of Treatment: Attractive result that masks stain.
Average Range of Treatment Life Expectancy: Three to ten years. ADVANTAGES
1. Can mask dark stains more esthetically than direct bonding.
2. No anesthetia usually required.
3. Can easily be repaired in the mouth if and when staining or chipping occurs.

68
4. More conservative-less tooth reduction than crowning.
5. Usually less expensive than crowning.
6. Color change possible.
DISADVANTAGES
1. Requires two visits.
2. Greater expense than bonded composites.
3. Can chip or fracture.
4. Can be an irreversible procedure if much enamel is removed.
5. Not as strong as porcelain laminates.
6. Greater wear than porcelain laminates.

PORCELAIN LAMINATES
Treatment Time: Two office visits. The teeth will be prepared and an impression made
during the first visit, which can take from one to four hours. The laminates will be fitted
and inserted at the second visit, which may also take the same amount of time. Expect to
spend more time for more extensive treatment.
Patient Maintenance: The teeth should be professionally cleaned three to four times
yearly. Warn your hygienist not to use ultrasonic scaling or air abrasive. Some
precautions on eating habits: as with bonding and crowning, take special care when biting
into or chewing hard foods with your laminated teeth, because they will not be as strong
as enamel. Margins eventually need resealing.
Results of Treatment: A polished, natural-appearing result that effectively masks stains.
Average Range of Treatment Life Expectancy: Average life expectancy is five to
twelve years.
ADVANTAGES
1. Less chipping than bonded restorations.
2. Etched porcelain provides an extremely good bond to enamel.
3. Wears less than the composite resin laminate.
4. Less stain-less chance of loss of color or luster.
5. More conservative-less tooth reduction than crowning.
6. Lasts five to twelve years as compared to plastics (three to eight years).

69
7. Gum tissue tolerates porcelain well.
8. No anaesthesia may be required.
9. Color change possible.

DISADVANTAGES
1. More costly than conventional bonding.
2. More difficult for dentist to produce a polished surface after contouring in the mouth.
3. More difficult to repair if the laminate cracks or chips.
4. Can be an irreversible procedure if much enamel is removed.

BASIC TYPES OF ESTHETIC CROWNS

ADVANTAGES
Ceramo-metal*
• Strongest type of esthetic crown.
• Doesn't fracture or chip as easily as altemative esthetic type crown.
• Usually most economical esthetic crowns.
Ceramo-metal crown with porcelain butt joint*
• Esthetic.
• No metal shows from front.
• Strong.
All-porcelain or cast glass
• Most esthetic throughout crown life.
• No metal shows.

DISADVANTAGES
• Metal may be visible if tissue shrinks.
• Metal may be visible if tissue is thin.
• Metal may affect color of porcelain.
• Possible bluish tint of gum if gum tissue is thin and metal shows through.

70
 • Metal usually visible from inside view only.
• Underlying metal may affect color of porcelain.
• Porcelain margin more susceptible to chipping than metal
• More costly to make
• Not as strong as ceramo-metal crown. Margin may be more susceptible to
chipping.

CROWNING
Treatment Time: Usually two appointments of approximately one to four hours each for
up to four teeth. Expect to spend more time as additional teeth or more extensive
treatment is involved.

Patient Maintenance: Crowns are designed to look and feel like real teeth. As with your
original smile, however, care must be taken to avoid tooth fractures. Biting down on hard
things like peanut brittle or ice is strictly prohibited. A caries-free or decay free diet
reduces intake of refined sugars is imperative to prevent the cement that helps hold the
crowns in place from washing away because of decay. Have a professional cleaning at
least three or four times yearly. Fluoride treatments should be given once a year. Ask
your dentist to recommend a fluoride toothpaste and mouthwash for you to use at home to
help prevent future decay. Usually, these products can be bought over the counter, but be
sure to choose well-tested products carrying the American Dental Association Seal of
Acceptance. Flossing at least once per day is essential for crowns. The most beautiful
results with full crowns can be destroyed if your teeth beneath the crowns decay.
Results of Treatment: Crowning can achieve the ultimate in shade control, tooth
shape and size.

Average Range of Treatment Life Expectancy: The average esthetic life of the full
crown is about five to fifteen years. Life expectancy is directly proportional to three
things: fracture, problems with tissues, and the hidden danger of decay.
ADVANTAGES
1. Teeth can be lightened or whitened to any desired shade.
2. The dentist can improve shapes of teeth during this process.

71
3. Some realignment or straightening of teeth is possible.
4. Longest life of any restoration.
DISADVANTAGES
1. Ceramic crowns can fracture.
2. Crowning requires an anesthetic.
3. Original tooth form is altered (possibly involving the nerve).
4. If tissue shrinkage occurs, it can expose the junction between tooth and crown,
allowing for the possibility of an unsightly line.
5. Crowning is not permanent; there is limited esthetic life expectancy.
6. Crowning requires much greater expense than bonding.

POSTERIOR PORCELAIN INLAY/ONLAY

Treatment Time: Two appointments of approximately one to two hours
each per tooth.

Patient Maintenance: Avoid biting hard objects in order not to fracture the porcelain.
Professional examination and cleaning two to four times per year. Daily flossing and
brushing same as natural teeth.
Results of Treatment: Porcelain inlays/onlays can successfully achieve both esthetic and
functional results in restoring discolored posterior teeth.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is
directly proportional to problems with tissues, fracture and danger of decay.
ADVANTAGES
1. Highly esthetic.
2. No metal shows.
3. Strong once bonded to tooth.
4. Long lasting.
DISADVANTAGES
1. Can chip.
2. Greater cost over amalgam or composite resin.
3. Can wear opposing tooth if you grind your teeth.

72
4. Takes two appointments.

POSTERIOR COMPOSITES
Treatment Time: One appointment of approximately one hour per filling.

Patient Maintenance: To keep resin-bonded restorations looking their best, you

should have a professional cleaning three or four times a year. Frequent cleanings
remove food stains that accumulate in microscopic
spaces on the bonded surfaces of the teeth. These bonded surfaces are not as strong as
your enamel, so try to protect them by eating wisely. For instance, avoid most foods that
stain. Expect to have some repolishing or repair as necessary.
Results of Treatment: Posterior resin bonded composites can restore as well as
esthetically match the natural tooth
Average Range of Treatment Life Expectancy: Average life expectancy is three to
eight years. May need repair or replacement more frequently.

ADVANTAGES
1. Tooth colored.
2. More economical than crowning or porcelain
inlay/onlay.
3. Produces an effective immediate seal from
restoration and enamel surface that can bond
weak or cracked teeth together.
4. Permits less tooth structure reduction.
DISADVANTAGES
1. Wears faster than silver, gold or porcelain restorations.
2. Can fracture.
3. Shorter life expectancy compared to gold, silver,
or porcelain.
4. Less suited for large cavities.
5. Can stain.

73
GOLD INLAY/ONLAY
Treatment Time: Usually two appointments one to
two hours per tooth.

Patient Maintenance: Normal brushing/flossing every day. Watch diet to avoid large
amounts of refined carbohydrates and chewy foods such as caramels and other candies
that can eventually eat away at the cement line and possibly cause decay under the gold
restoration. Use fluoride mouth rinse and toothpaste.
Results of Treatment: Best functional and longest lasting method of restoring teeth, but
does tend to show metal of large restoration. However, can be "antiqued" or sanded to
dull gold reflectance.
Average Range of Treatment Life Expectancy: Five to twenty years.

AMALGAM
Treatment Time: One appointment, approximately one half hour to one
hour per tooth.

Patient Maintenance: Normal brushing and flossing every day. Limit refined sugars,
such as candy, which can attack margins, causing decay around and under fillings. Use
fluoride mouth rinse and toothpaste.
Results of Treatment: Still the most common of posterior filling replacements. Not as
technique-sensitive as other materials. Silver color may be visible depending on where
and how large the restoration is.
Average Range of Treatment Life Expectancy: Five to twelve years.

POSTERIOR CROWNS
Treatment Time: Two to three appointments, approximately one to two
hours per tooth.

74
Patient Maintenance: Normal brushing and flossing. Fluoride mouth rinse and
toothpaste as prescribed by your dentist. Same dietary restrictions as above for longest
restorative life.
Results of Treatment: Crowning can achieve the ultimate in shade control, tooth shape
and size.
Average Range of Treatment Life Expectancy: Five to fifteen years.

THE FOUR MOST POPULAR POSTERIOR RESTORATIVE MATERIALS.

1. GOLD INLAYS/ONLAYS
ADVANTAGES
• Longest lasting.
• Wears more like tooth structure.
• Will not fracture.
• Well suited for large cavities.

DISADVANTAGES
• Metal can show.
• Takes two appointments.
• More costly than amalgam or composite
resin.
• Non insulative (conducts heat and cold).

2. SILVER AMALGAM
ADVANTAGES
• One appointment.
• Least costly.
• Predictability Long life.
DISADVANTAGES
• Metal can show.

75
 • Tooth may discolor.
• Can corrode.
• Contains mercury.
• Not sealed to tooth.
• Non insulative.
• Less suited for large cavities (ie, covering
a cusp).

3. POSTERIOR COMPOSITES
ADVANTAGES
• Esthetic (tooth colored).
• Insulative.
• One appointment.
• Well-sealed to tooth (bonds to tooth
structure).
• More economical than crowning or porcelain inlays.
DISADVANTAGES
• More costly than amalgam.
• Wear faster.
• Can stain.
• Can chip or fracture.
• Shorter life expectancy compared to silver,
gold or porcelain.
• Less suited for large cavities.

4. PORCELAIN ANLAYS/ONLAYS
ADVANTAGES
• Highly esthetic.
• Stronger than posterior composite resins.
• Well sealed to tooth.
76
 • Will not stain.
• Insulated.
• Well suited for large cavities.
DISADVANTAGES
• Can fracture.
• More costly than amalgam or composite
• Porcelain takes two appointments ( except CAD-CAM, which can be done in one
appointment)
• Possible wear of opposing natural tooth.

COSMETIC CONTOURING
Treatment Time: 15 to 60 minutes.
Patient Maintenance: Normal cleaning.
Results of Treatment: Teeth can appear straighter immediately after treatment.
Average Range of Treatment Life Expectancy: Indefinite.

ADVANTAGES
1. No anesthesia is required
2. Permanent solution
3. No maintenance
4. Most-conservative
5. Quickest solution
DISADVANTAGES
1. Too much reduction can alter the appearance of the smile line and may be unattractive
2. Bite may limit how much of the tooth can be removed
3. In rare instances sensitivity may be a problem
BONDING
Treatment Time: 1 to 2 hours per tooth.
Patient Maintenance :Professional cleaning three or four times a year. Eat wisely as
these teeth can chip easily. Floss in and pull it through rather than popping it out. Because
staining or chipping can occur, expect to have some repolishing or repair as necessary.

77
Results of Treatment :Most fractures and chips can be easily repaired with bonding.
Average Range of Treatment Life Expectancy: Five to eight years, with professional
finishing once every few years.
ADVANTAGES
1. No anaesthesia required
2. Little tooth reduction required
3. Immediate results
4. Teeth can also be lightened
5. Less expensive than crowning
DISADVANTAGES

1. Can chip or stain

2. Bonding has a limited esthetic life
3. May not work for severe fractures

SPARE CROWNS
ADVANTAGES
1. Less expensive than starting over
2. You get instant replacement in case of fracture
3. You can save the cost of a temporary or an extra office visit
4. You could beat inflation; your crowns could cost more later
DISADVANTAGES
1. Your initial cost is more
2. You may never need the extra set
3. Your tooth underneath may change drastically with time and then the spare crowns
would not fit properly
4. If your gum line changes around the neck of the tooth over the years, the spare crowns
may be useless

CROWNING

78
Treatment Time: Usually two appointments of approximately one to four hours on up to
four teeth. Expect to spend more time as additional teeth or more extensive treatment is
involved.

Patient Maintenance: Crowns are esthetically designed to look and feel like "real teeth."
As with your original smile, however, care must be taken to avoid tooth fractures. Yearly
fluoride treatments may be advised. Flossing every day is as essential with crowns as
with natural teeth.
Results of Treatment: Badly fractured teeth may be repaired and reshaped as desired.
Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is
directly proportional to problems with tissues, fracture and danger of decay.
ADVANTAGES
1. The dentist can repair the chipped or fractured tooth
2. Teeth can be lightened to any shade
3. Some realignment or straightening of the teeth is possible

DISADVANTAGES
1. Crowns can fracture
2. Procedure requires anesthesia
3. Original tooth form is altered
4. It is not permanent
5. It is more costly than bonding

SOLUTIONS FOR SPACING PROBLEMS

• Orthodontics to reposition teeth
• Bonding or laminating to restore teeth
• Crowning or "capping" to restore teeth .
• Removable acrylic overlay
• Bridges to replace missing teeth
• Implants to replace missing teeth

79
ORTHODONTICS
Treatment Time: Six to twenty-four month for most
patients.

Patient Maintenance: Special care by the patient by cleaning daily and checkups on a
scheduled basis.
Retainers frequently have to be worn at night for many years, at least a few nights a
week, possibly indefinitely, to maintain tooth alignment. A water-powered cleaning
device is also helpful if used daily.
Results of Treatment: Spaces between teeth are closed.
Average Range of Treatment Life Expectancy: Generally permanent.
ADVANTAGES
1. Closes space between teeth
2. Permanent solution for most individuals
3. No tooth reduction required
4. May be the least expensive treatment (compared
to crowning or bonding replacement)
DISADVANTAGES
1. Time-consuming (six to twenty-four months)
2. Teeth may return to original position if retainers are not worn
3. It is more difficult to clean teeth during treatment

BONDING
Treatment Time: One to two hours per
tooth.

Patient Maintenance: Professional cleaning three or four times yearly. Avoid hard
foods on front teeth. Bonding to fill in a space is more susceptible to chipping. Proper use
of floss daily is required. One problem with most direct bonded restorations is that they
can stain or chip. Expect to have some repolishing or repair as necessary.
Results ofTreatment: Most spaces can be filled in to look very
natural. '

80
Average Range of Treatment Life Expectancy: Five to eight years. Professional
refinishing once every year.
ADVANTAGES
1. Little or no reduction of tooth structure
2. No anesthesia required
3. Reversible procedure
4. Economical, more so than crowning
5. Teeth can also be lightened
DISADVANTAGES
1. Can chip or stain more easily than crowns
2. Has limited esthetic life
3. Treatment may involve extra teeth to obtain proportionate space closing
4. Teeth may appear somewhat thicker
PORCELAIN LAMINATES
Patient Maintenance: The teeth should be professionally cleaned about three to four
times yearly. Some precautions on eating habits: as with bonding and crowning, take
special care when biting into or chewing hard foods with your laminated teeth, since they
will not be as strong as enamel.
Treatment Time: Two office visits. The teeth will be prepared and an impression made
during the first visit, which can take from one to four hours. The laminates will be fitted
and inserted during the second visit, which may also take the same amount of time.
Expect to spend more time for more extensive treatment.
Results of Treatment: A polished, natural-appearing result that effectively closes spaces
Average Range of Treatment Life Expectancy: Four to twelve years. ADVANTAGES
1. Easier to obtain proportionate closure of spaces
2. Less chipping than bonded restorations
3. Etched porcelain provides an extremely good bond to enamel
4. Wears less than the composite resin laminate
5. Less stain-less chance of color or luster loss
6. More conservative-less tooth reduction than
crowning

81
7. Lasts four to twelve years as compared to plastics
(three to eight years)
8. Gum tissue tolerates porcelain well
9. No anesthetic usually required
10. Color change possible
11. Less expensive than crowning
DISADVANTAGES
1. More costly than conventional bonding
2. More difficult for dentist to produce a polished surface after contouring in the
mouth
3. More difficult to repair if the laminate cracks or chips
4. Can be an irreversible procedure if much enamel is removed

CROWNING
Treatment Time: Usually two appointments of approximately one to four hours on up to
four teeth. Expect to spend more time as more teeth are treated or more extensive
treatment is performed.

Patient Maintenance: Crowns are designed to look and feel like real teeth, but extra care
must be taken to avoid tooth fractures in order to protect the remaining natural tooth root.
Fluoride treatments should be given once a year. Flossing every day is essential with
crowns.
Results of Treatment: Crowning can achieve the ultimate in shaping
teeth to fill spaces.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is
directly proportional to problems with tissues, fractures and recurrent decay.
When to Crown: When tooth enamel is insufficient to bond
ADVANTAGES
1. Crowns can be shaped to esthetically fill gaps
2. Teeth can be lightened to any shade
3. Some realignment or straightening of the teeth is possible
4. Should last about twice as long as bonding

82
DISADVANTAGES
1. Can fracture
2. Requires anesthesia
3. Original tooth form is altered
4. May need to be replaced after five to fifteen years
5. More costly than bonding

CONVENTIONAL FIXED BRIDGE

Treatment Time: Two to four weeks
Patient Maintenance: Daily cleaning under bridge with floss threaders. Results of
Treatment: Esthetic replacement of lost tooth or teeth.
Average Range of Treatment Life Expectancy: Five to fifteen years. ADVANTAGES
1. Longest life
2. Easy to clean
3. Improves your bite
4. Helps prevent movement of adjacent and opposing teeth
DISADVANTAGES
1. Difficult to match shade of porcelain
2. Costs more than cantilever
3. More tooth reduction than cantilever or resin bonded bridge
4. May be difficult to make look natural in cases of ridge or gum loss
CANTILEVER FIXED BRIDGE
Treatment Time: Two to four weeks
Patient Maintenance: Must clean under bridge. Easier to use floss threaders.
Results of Treatment: Esthetic tooth replacement
Average Range of Treatment Life Expectancy: Five to fifteen years average life.
ADVANTAGES
1. Less tooth structure reduced because fewer teeth required
2. Less expensive than conventional bridge
3. More natural separation possible between teeth
DISADVANTAGES

83
1. Less structural support
2. Unless the bite is perfectly balanced, too much torque can damage the replacement
tooth
RESIN-BONDED FIXED BRIDGE
Treatment Time: Two to four weeks.
Patient Maintenance: Same as for conventional bridge. Daily cleaning under bridge
with floss threaders.
Results of Treatment: Tooth replacement without reducing other teeth.
Average range of treatment life expectancy: 5 to 10 years.
Treatment Time: Four to eight weeks.
ADVANTAGES
1. Less expensive than conventional bridge
2. No anesthesia required
3. Less tooth reduction
DISADVANTAGES
1. Less ability to alter shape and sizes of teeth
2. Tissue can shrink around gum, leaving spaces between teeth
3. Metal backing may show through if the teeth are thin
4. Teeth to which the bridge is attached must be in excellent condition
5. May not last as long as a conventional bridge

CONVENTIONAL REMOVABLE BRIDGE

Treatment Time: Four to eight weeks.
Patient Maintenance: Must remove bridge and clean after eating.
Results of Treatment: Least expensive way to replace missing teeth.
Average Range of Treatment Life Expectancy: Five to ten years.
ADVANTAGES
1. Less expensive than fixed bridges.
2. Helps to balance bite and increases chewing efficiency by replacing missing teeth
3. Prevents movements of adjacent and opposing teeth
DISADVANTAGES

84
1. Attachment may create possible wear and stress on supporting teeth
2. May not be as esthetic as a fixed bridge

PRECISION-ATTACHMENT REMOVABLE BRIDGE

Treatment Time: Four to eight weeks.
Patient Maintenance: Requires regular cleaning and adjustments.
Results of Treatment: Removable bridge is less obvious.
Average Range of Treatment Life Expectancy: Five to ten years.
ADVANTAGES
1. Clasps are hidden
2. Superior retention
DISADVANTAGES
1. More expensive than clasps
2. Attachments can break
3. Attachments can wear

OVERDENTURE
Treatment Time: Four to eight weeks.
Patient Maintenance: Requires daily cleaning and periodic adjustments.
Results of Treatment: Hides the fact you are wearing a removable bridge.
Average Range of Treatment Life Expectancy: Five to ten years.
ADVANTAGES
1. Saves roots
2. Improves chewing ability
3. Better fit and retention as compared to normal denture
4. Less stress to supporting ridge tissue
5. Provides a good transition to a full denture
6. Allows the patient to retain some tactile sensation
DISADVANTAGES
1. Attachment can break
2. More costly than conventional denture

85
3. May be slightly bulkier than fixed or removable partial dentures

IMMEDIATE DENTURE
Treatment Time: Two visits over a two- to four-week period.

Patient Maintenance: Cleaning after meals to remove and prevent stains on dentures.
Check probable gum shrinkage with your dentist. Requires relining.
Results of Treatment: Can duplicate or improve your tooth color, form and tooth
arrangement.
Average Range of Treatment Life Expectancy: Usually no more than six months, but
with a reline at approximately three months, can last much longer
ADVANTAGES
1. You do not have to be seen without teeth
2. Helps keep ridge protected during healing following extractions
3. Easier transition to final denture
4. Can act as final denture

DISADVANTAGES
1. May require a final denture to be made
2. Possible added expense
3. Requires relining
4. May require frequent adjustments

FULL DENTURE
Treatment Time: Two to four weeks
Patient Maintenance: Cleaning after meals to remove and prevent stains on denture.
Results of Treatment: Esthetically pleasing results are possible.

Average Range of Treatment Life Expectancy: Five to ten years. Tooth fracture may
occur, and the need for relining may be necessary during this time.
ADVANTAGES
1. Maximum esthetics possible

86
2. More youthful appearance obtainable
3. Supports lips and cheeks
4. Can improve speech
DISADVANTAGES
1. Less chewing efficiency
2. Retention may be a problem
3. Needs maintenance
4. May need to be replaced every five to ten years
5. May impede speech in some instances

IMPLANTS
Treatment Time: Surgical placement time per implant is approximately one hour
depending on the complexity of the procedure. Healing is approximately three months in
the lower jaw and six months in the. Upper jaw while the implant permanently attaches
to the bone. After healing, another appointment may be necessary to uncover the implant
and place a healing cap so your dentist can construct a final crown.
Patient Maintenance: Daily flossing and home care as instructed by your dentist.
Professional cleanings four times per year. Exam by restorative dentist at least once a
year.

Results of Treatment: Best approximates having your own natural tooth (or teeth).
Provides tooth that is natural appearing and individually functioning. Avoids unnecessary
tooth structure removal on natural adjacent teeth.
Average Range of Treatment Life Expectancy: Once successfully integrated into the
bone, the implant can last indefinitely, barring infection.

COSMETIC CONTOURING
Treatment Time: About one hour.
Patient Maintenance: Normal brushing and flossing.

Results of Treatment: Immediate reshaping of tooth structure makes crowded teeth

appear the appropriate size.

87
Average Range of Treatment Life Expectancy: Indefinite.
ADVANTAGES
1. Less expensive than other forms of esthetic treatment
2. Permanent results
3. Immediate problem correction
4. Minimum treatment time
5. Generally painless; requires no anesthesia
DISADVANTAGES
Teeth are not repositioned
2. Improvement may be limited by functional consideration
3. Possibly some discomfort for children with large pulp canals
4. No improvement in color

BONDING
Treatment Time: One to two hours per tooth.

Patient Maintenance: Professional cleaning three to four times yearly. Eat wisely-these
teeth can chip easily. Floss in and pull it through rather than popping the floss out. Expect
some chipping or porosity to eventually occur requiring a repair.
Results of Treatment: Straighter teeth in one appointment.
Average Range of Treatment Life Expectancy: Five to eight years.
ADVANTAGES
1. Conservative because there is little or no reduction of tooth structure
2. Reversible procedure
3. More economical than laminating or crowning
4. No anesthesia required
5. Teeth appear straighter
DISADVANTAGES
1. Does not reposition the tooth
2. The gums can become inflamed because of the crowding; in this case the basic
problem is not corrected
3. Needs to be redone more often

88
4. Can stain or chip more than crowns
5. Teeth may appear some what thicker

PORCELAIN LAMINATES
Treatment Time: Two office visits. The teeth will be prepared and an impression made
on the first visit, which can take from one to four hours. The laminates will be fitted and
inserted at the second visit, which may take the same amount of time. Expect to spend
more time for more extensive treatment.
Patient Maintenance: The teeth should be professionally cleaned about three to four
times yearly. Some precautions: as with bonding and crowning, take special care when
chewing hard foods or biting into foods with your laminated teeth, to avoid chipping or
potential fracture.
Results of Treatment: Polished, natural-appearing results that can make teeth appear
straighter.
Average Range of Treatment Life Expectancy: Four to twelve years
ADVANTAGES
1. Less chipping than with bonded restorations
2. Etched porcelain provides an extremely good bond to enamel
3. Wears less than the composite resin laminate
4. Less stain-does not lose color or luster
5. Can make more proportional results because
they are constructed in lab
6. Lasts four to twelve years, as compared to plastics (three to ten years)
7. Gum tissue tolerates porcelain well
8. No anesthetic usually required
DISADVANTAGES
1. More costly than conventional bonding
2. More difficult to repair if the laminate cracks or chips
3. May eventually need repair or resealing of the margins if the cement washes out or
debonds.

89
CROWNING
Treatment Time: Usually two appointments of approximately one to four hours for up to
four teeth. Expect to spend more time as additional teeth or more extensive treatment is
included.

Patient Maintenance: Care in biting hard objects to avoid fracturing the crowns.
Fluoride treatments once yearly along with the use of fluoride toothpaste and flossing
every day.
Results of Treatment: Crowning can achieve the ultimate esthetic results in reshaping
overly crowded teeth.
Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is
directly proportional to problems with tissue, fracture, and the danger of decay
ADVANTAGES
1. Teeth can be lightened to any shade
2. Takes less time than orthodontics
3. Crowned teeth stain less than bonded teeth
4. Longer life than composite resin bonding or porcelain laminates
5. Offers greatest latitude in improving tooth form
DISADVANTAGES
1. Can fracture
2. Requires anesthesia
3. Altered tooth form
4. Is not permanent; may need to be replaced after five to fifteen years
5. More costly than contouring or bonding
6. Is irreversible
7. May trigger pulp irritation in rare instances
8. May induce tooth sensitivity for a short time
ORTHODONTICS
Treatment Time: Six to thirty six months.
Patient Maintenanc:. Special attention to daily cleaning; adjustment check ups every
three to four weeks. Retainers will need to be worn at night indefinitely
Results of Treatment: Crowded and overlapped teeth can be

90
straightened.
Average Range of Treatment life Expectancy: Generally a permanent treatment, but
will usually require wearing a retainer at least a few nights weekly.
ADVANTAGES
1. Can straighten misaligned teeth
2. Permanent solution for most individuals
3. Little or no tooth reduction required
4. May be less expensive than laminating, crowning or bonding, depending on the
number of teeth involved
5. Improved tissue health due to better cleaning access
DISADVANTAGES
Time-consuming (six to thirty-six months)
2. Teeth may return to original position if retainers are not worn
3. May take a few weeks to get used to appliances
Best advice: With your dentist, develop a master treatment plan before starting
orthodontic therapy. Be sure to include other treatment that may become necessary
after orthodontic therapy is completed.

COMPARATIVE TREATMENTS OF OPEN BITE

1. ORTHODONTICS
ADVANTAGE:
• Will improve ability to bite.

2. ORTHOGNATHIC SURGERY
ADVANTAGES
• Can improve facial esthetics
• May be only method available to correct deformity Results are usually permanent
DISADVANTAGES
• General anesthesia required
• Jaws may require fixation following surgery; limited
• jaw opening for the first several weeks

91
 • Requires orthodontic treatment as well
COMPARATIVE TREATMENTS OF CLOSED BITE OR DEEP
OVERBITE

1. ORTHODONTICS (DEEP OVERBITE)

Most preferable
Longest lasting
Can help

2. ORTHOGNATHIC SURGERY
Treatment Time: One to three months.
Patient Maintenance: Meticulous daily care of the mouth and teeth while the jaws are
wired together.

Results of Treatment: Usually jaw problems and facial esthetics are improved by
rearranging the jaw
bones and possibly adding implants, removal of fatty
tissue, etc.
Average Range of Treatment Life Expectancy: For the most part, the treatment is
permanent.
Cost: Several hundred to several thousand dollars, depending upon the treatment.
ADVANTAGES
1. Some jaw problems can be treated only
by surgery
2. The procedures are usually accomplished
in one or two visits at either a hospital or
office surgical suite
3. Although surgery can be costly, it may be
covered by insurance
4. In most cases, self image is greatly
improved, which may help relationships,
career advancement and quality of life

92
DISADVANTAGES
1. Surgery is required
2. Jaws may be wired together for six to eight weeks
3. Surgery may be costly, especially if not
covered by insurance
4. Facial swelling and discomfort, with associated
inconveniences, may last several weeks
5. May cause a negative personality change in
unstable individuals
6. If plastic implants are used, they may become
infected or shift
7. Facial numbness may result temporarily or
permanently
HOW TO AVOID AN AGING SMILE
1. Watch for unnatural wear. It ages the smile.
2. Avoid bone and gum loss. Spaces between the teeth can give an older look to the smile.
Take proper oral hygiene seriously and request frequent periodontal evaluation from your
dentist.
3. Replace fillings when necessary.
4. Don't let your crowns or bridges age you. If they are worn down, replace them.
5. Have any discolored teeth corrected. Staining makes you look older.
6. Replace any missing teeth as soon as possible. Missing teeth can cause your bite to
collapse and tissues to sag.
7. Correct your bad bite. As you age, the bad bite tends to become more pronounced. It's
never too late to have it corrected!

PREVENTION: THE BEST WAY TO FIGHT THE YEARS

You can keep your smile intact for a lifetime. Good oral hygiene-including tooth
brushing, flossing and regular visits to the dentist-will help keep teeth, gums and bone in
good health.
Proper tooth brushing is one of the best ways to prevent tooth loss and other

93
problems. If you're not sure that you're brushing correctly, ask your dentist to show you
how. Although a loss of tooth structure due to mechanical wear is inevitable, incorrect
tooth brushing often accelerates this process. You may also want to purchase chewable
disclosing tablets that allow you to see the plaque you missed by revealing those areas in
red.
You should also consider purchasing a rotary cleaning device with the advice of
your dentist. Research has shown that many people can improve their tooth cleaning
ability with automatic tooth brushes.
Also choose a dentist who offers an aggressive program of preventive maintenance.
This should include two to eight professional tooth cleanings per year, proper home care
instruction, monitoring of plaque control and referral to specialists such as periodontists
when needed.
Finally, don't neglect to replace teeth that are lost. Failure to do so can result in more
extensive-and expensive-dental treatment in the long run than replacing them. Leaving a
space in the back of the mouth can lead to gum disease or throw off the bite by shifting
chewing pressure to other teeth. This, in turn, can cause the front teeth to shift. In fact,
newly developed spaces between front teeth are often the result bf missing back teeth, so
don't let it happen.
Never have your teeth extracted if there is sufficient bone to save them, even if only
a root remains. You will chew better-and look better-if you restore, rather than replace
your natural teeth.
If your bone is diseased, periodontal surgery can often allow you to save your teeth.
And your own good roots are always better "implants" than artificial ones.

THE BEST WAY TO LOOK YOUNGER

The best way to obtain a more youthful smile is by combining the advantages of cosmetic
dentistry, plastic surgery and cosmetology-in that order.
First, improve your smile. Make sure it looks healthy and younger. Next, if you're
concerned about sagging facial tissue, consider plastic surgery. And finally, don't forget
that a new hairstyle and updated makeup can provide the finishing touches (see p. 297).

94
NEVER STOP CARING

With age, some people simply give up trying to look their best and stop taking proper
care of themselves, including their teeth. As a result, their teeth become worn and
discolored, fillings decay and gum disease sets in. If you're one of those people,
remember that it's never too late to start taking care of yourself again. Many older persons
today are seeking treatment to correct dental problems and improve their appearance. If
you have friends or family members who no longer take an interest in their looks, share
this book with them. Let them know how much better they can feel with a brand new
smile. You could be a tremendous help in improving not only their appearance, but their
outlook on life.

REFERENCES:

1. Albino JE, Tedesco LA. Patient perception of dental-facial esthetics. Shared concerns
in prosthodontics and orthodontics. J Prosthet Dent 1984;52:9.

2. BHALAJI SI. ORTHODONTICS:THE ART AND SCIENCE. PR PUBLICATIONS,

2002

3. Burckett PJ, Christensen LC. Estimating age and sex by using color, form and
alignment of anterior teeth. J Prosthet Dent. 1988;59:175-9.

4. Burns DR, Beck DA, Nelson SK A review of selected dental literature on

contemporary provisional fixed prosthodontic treatment: report of the Committee on
Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics. J Prosthet
Dent. 2003 Nov;90(5):474-97.

5. Brigante RF. Patient assisted esthetics. J Prosthet Dent 1981;46:14.

95
6. CARRANZA FA. NEWMAN MG. CLINICAL PERIODONTOLOGY. WB
SAUNDERS CO. 1996

7. CHICHE GJ, PINAULT A. AESTHETICS OFANTERIOR FIXED

PROSTHODONTICS. CHICAGO: QUINTESSENCE 1994.

8. Christensen GJ. Ensuring retention for crowns and fixed prostheses. J Am Dent Assoc.
2003 Jul;134(7):993-5.

9. DAWSON PETER. EVALUATION, DIAGNOSIS AND TREATMENT OF

OCCLUSAL PROBLEMS. CV MOSBY, 1989.

10. Donovan TE, Chee WW. A review of contemporary impression materials and
techniques. Dent Clin North Am. 2004 Apr;48(2):vi-vii, 445-70.

11. Ehrlich J, Gazit E. Relationship of the maxillary central incisors and canines to the
incisive papilla. J Oral Rehabil. 1975 Jul;2(3):309-12.

12. Flores-Mir C, Silva E, Barriga MI, Lagravere MO, Major PW. Lay person's
perception of smile aesthetics in dental and facial views. J Orthod. 2004 Sep;31(3):204-9;
discussion 201.

13. Frindel F. Sixteen keys for building a youthful smile Orthod Fr. 2003 Mar;74(1):83-
102.

14. Gillet D, Miquel JL, Jeannel A. Patients, practitioners, faculty and dental esthetics:
the same level of perception? Odontostomatol Trop. 2002 Jun;25(98):5-11.

15. GOLDESTEIN RE. CHANGE YOUR SMILE. CAROL

STREAM,ILLINOIS:QUIENTESSENCE, 1997

16. GOLDESTEIN RE. AESTHETICS IN DENTISTRY. BC DECKER Inc., 1998.

17. Grove HF, Christensen LV. Relationship of first primary palatine rugae to the
maxillary canines in man. J Oral Rehabil. 1988 Mar;15(2):133-9.

18. Hirshberg SM. The relationship of hygiene to embrasure and pontic design. AA
preliminary study. J Prosthet Dent. 1972; 27:26-38.

19. Ibbetson R. Clinical considerations for adhesive bridgework. Dent Update. 2004
Jun;31(5):254-6, 258, 260 passim.

96
20. Jameson WS. Dynesthetic and dentogenic concept revisited. J Esthet Restor Dent.
2002;14(3):139-48.

21. Kern BE. Anthropometric parameter of tooth selection. J Prosthet Dent 1967; 17:431.

22. Krajicek OD. Simulation of natural appearance. J Prosthet Dent. 1962; 12:28-32.
23. Lau GC, Clark RF. The relationship of the incisive papilla to the maxillary central
incisors and canine teeth in southern Chinese. J Prosthet Dent. 1993 Jul;70(1):86-93.

24. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent. 1978
Sep;40(3):244-52.

25. Lombardi R. Visual perception and dental esthetics. J Prosthet Dent 1973; 29:352-
382.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

25. Lombardi R. Visual perception and dental esthetics. J Prosthet Dent 1973; 29:352-
382.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

25. Lombardi R. Visual perception and dental esthetics. J Prosthet Dent 1973; 29:352-
382.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

24. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent. 1978
Sep;40(3):244-52.

97
25. Lombardi R. Visual perception and dental esthetics. J Prosthet Dent 1973; 29:352-
382.

26. Lombardi RE. A method for the classification of errors in dental esthetics. J Prosthet
Dent 1974; 32:501.

27. Lombardi RE. Factors mediating against excellence in dental esthetics. J Prosthet
Dent. 1977 Sep;38(3):243-8.

28. Lundeen HC, Shryock EF, Gibbs CH. An evaluation of mandibular border
movements: their character and significance. J Prosthet Dent. 1978 Oct;40(4):442-52.

29. MacArthur DR. Are anterior replacement teeth too small? J Prosthet Dent 1987;
57:462-465.

30. Mack MR. Vertical dimension: a dynamic concept based on facial form and
oropharyngeal function. Prosthet Dent. 1991 Oct;66(4):478-85.

31. Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J

Prosthodont. 1999 Jun;8(2):106-18.

32. Martone AC. Anatomy of facial expressions and its prosthodontic significance. J
Prosthet Dent 1962; 12:1020-1041.

33. Matthews TG. The anatomy of smile. J Prosthet Dent 1978; 39:128-134.
34. Mavroskoufis F, Ritchie GM. Nasal width and incisive papilla as guides for the
selection and arrangement of maxillary anterior teeth. J Prosthet Dent. 1981
Jun;45(6):592-7.

35. McArthur DR. Determination of approximate size of maxillary anterior denture teeth
when mandibular anterior teeth are present. Part III: Relationship of maxillary to
mandibular central incisor widths. J Prosthet Dent. 1985 Apr;53(4):540-2.

36. Miller EL, Bodden WR Jr, Jamison HC. A study of the relationship of the dental
midline to the facial median line. J Prosthet Dent. 1979 Jun;41(6):657-60.

98
37. Naylor CK. Esthetic treatment planning: the grid analysis system. J Esthet Restor
Dent. 2002;14(2):76-84.

38. Neves FD, Mendonca G, Fernandes Neto AJ. Analysis of influence of lip line and lip
support in esthetics and selection of maxillary implant-supported prosthesis design. J
Prosthet Dent. 2004 Mar;91(3):286-8.

39. OKESSON JP. MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS

AND OCCLUSION. MOSBY

40. Olsson KG, Furst B, Andersson B, Carlsson GE. A long-term retrospective and
clinical follow-up study of In-Ceram Alumina FPDs. Int J Prosthodont. 2003 Mar-
Apr;16(2):150-6.

41. Ortman HR, Tsao DH. Relationship of the incisive papilla to the maxillary central
incisors. J Prosthet Dent. 1979 Nov;42(5):492-6.

42. PATIL R. AESTHETIC DENTISTRY: AN ARTISTS SCIENCE. PR

PUBLICATIONS, 2002.

43. Pound E, Muriel G. An introduction to denture simplification. J Prosthet Dent. 1971;

26,571-580.

44. Preston JD. A systematic approach to the control of esthetic form. J Prosthet Dent.
1976 Apr;35(4):393-402.

45. Rifkin R, McLaren E. Treatment selection for anterior endodontically involved teeth.
Pract Proced Aesthet Dent. 2004 Sep;16(8):553-60; quiz 561.

46. Rosenstiel SF, Ward DH, Rashid RG. Dentists' preferences of anterior tooth
proportion--a web-based study. J Prosthodont. 2000 Sep;9(3):123-36.

47. RUFENACHT CR. FUNDAMENTALS OF ESTHETICS ILLINOIS

QUIENTESSENCE1992

99
48. Schneider RL, Curtis ER, Clancy JM. Tensile bond strength of acrylic resin denture
teeth to a microwave- or heat-processed denture base. J Prosthet Dent. 2002
Aug;88(2):145-50.

49. Seluk LW, Brodbelt RH, Walker GF. A biometric comparison of face shape with
denture tooth form. J Oral Rehabil. 1987 Mar;14(2):139-45.

50. SHILLINGBERG etal. FUNDAMENTALS OF FIXED PROSTHODONTICS.

QUINTESSENCE.

51. Simon J. Using the golden proportion in aesthetic treatment: a case report. Dent
Today. 2004 Sep;23(9):82, 84.

52. Smukler H, Chaibi M. Periodontal and dental considerations in clinical crown

extension: a rational basis for treatment. Int J Periodontics Restorative Dent. 1997
Oct;17(5):464-77.

53. Snow SR. Esthetic smile analysis of maxillary anterior tooth width: the golden
percentage. J Esthet Dent. 1999;11(4):177-84.

54. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978
May;39(5):502-4.

55. Weinberg LA. Esthetic and the gingiva in full coverage. J Prosthet Dent 1960;10:737-
744.

56. WHEELER’S DENTAL ANATOMY

CONCLUSION

The change in dentistry from need based dentistry to elective dentistry has made a
significant impact on the profession and the public perception of dentists. It is estimated
that up to one half of the dentistry accomplished at this time is elective. Much of this
treatment is what could be considered to be esthetic dentistry including bleaching,
bonding, veneers, tooth colored inlays and onlays, non metallic crowns and fixed
prosthesis, orthodontics and surgical procedures, and many other procedures.

100
Dentists and their staff must be proactive in their patient educational activities to
stimulate patients to desire these elective procedures. If dentists ask for patients to ask for
the procedures, practice activity can be influenced negatively.

This dissertation will assist interested persons in becoming updated in the broad scope of
esthetic dentistry. Self instruction is perhaps the best way to cope with the expanding area
of esthetic dentistry.

1. Weinberg LA.55 (1960) This article emphasizes the dynamic relationship of the design
and construction of full coverage restorations with regard to esthetic appearance and
gingival health. Esthetic appearance with full coverage restorations is dependent on
anatomic form, the materials used, and the maintenance of gingival health.

2. Krajicek OD.22 (1962) Natural appearance is one of the more easily achieved
objectives in complete denture construction. The overall appearance of the denture is
important, but only to the extent that it contributes to a natural appearance and function of
the face and lips. Practical guiding principles have been suggested which are designed to
break the appearance barrier and place this phase of Prosthodontics on a sound basis.

3. Martone AC.32 (1962) An understanding of the muscles of facial expression is

important to successful complete denture construction. These muscles may be observed at

101
work by the dentist when he first views his patient and that patient begins to speak. An
understanding of its prosthodontic significance enables the dentist to employ post
operative vision in the treatment planning stage which can minimize denture failures.
Prosthodontic treatment must be in terms of all of the functions performed within the
mouth region. In recognition of this, the present study was conducted to (1) consider the
role which the facial muscles play in expression. (2) analyze these muscles in terms of the
expressions of various emotions, and (3) evaluate their prosthodontic significances.
Certain suggestions have been made as to the role muscles of facial expressions may play
in non-masticatory movements of the mandible.

4. Kern BE.21 (1967). A study of many skulls was made to determine the ratios between
the size of certain bony structures and the size of the anterior teeth. Several commonly
used ratios were not verified, but relatively more consistency was found in others. Of
particular significance was the ratio of the nasal width to the combined widths of the
maxillary incisor teeth.

5. Pound E, Muriel G.43 (1971) The past and present approaches to complete denture
construction have been analyzed in the hope of developing more simplified methods.
They have emphasized on a new approach to patient education and management, and
almost a complete reversal in the sequence of events in denture construction. The
resultant methods have sufficient versatility to satisfy varying patient problems, planned
cost requirements, and to produce results that are gratifying to both dentist and patient.

6. Hirshberg SM.18 (1972)

a. Oral hygiene exerts a more important influence on the health of the gingiva and
mucosa adjacent to fixed prosthesis than does the height of the embrasure.
b. Poor oral hygiene causes inflammation of the interdental gingiva, mucosa and filling in
of the embrasures. Even with ideal oral hygiene, there is a slight increase in the size of
the interdental gingiva and mucosa.
c. The oral mucosa is more llikely to remain healthy under spheroidal or modified
sphreoidal pontics than under ridge lap pontics.

102
7. Lombardi R.25 (1973) A real need for a very detailed, almost histologic approach to
dental esthetics exists. Indeed, the perspective principles may be regarded as the cellular
elements of which the tissue of denture esthetics is composed. As familarity with the
principles increases, so does proficiency in their application. With experience, the basic
shape and characteristics of the dental tooth arrangement can be visualised even before a
single tooth is placed in wax. All that remains is a detailed examination at try-in to look
for minor perspective conflicts, and this too becomes less of a task with the training of the
eye to really see.

8. Lombardi RE.26 (1974) The purpose of this article is to suggest a method of

classification of esthetic errors in tooth arrangement. Most tooth arrangement errors fit
into an outline based entirely upon two factors: (1) the relationship between the dental
composition (the denture) and its background (the patient) and (2) the relationship of the
various elements within the dental composition.

9. Ehrlich J, Gazit E.11 (1975) Four hundred and thirty dentulous casts in normal
alignment and Angle's Class I Relationship were examined. The results indicated a
relationship between arch shape and the incisive papilla. The suggestion is made that in
the preliminary location of the anterior teeth during construction of full dentures, the
average distance of incisors and canines from the incisive papilla could be used as
starting points.

10. Preston JD.44 (1976). A systematic, orderly approach to the problem of establishing
harmonious phonetics, esthetics, and function in fixed restorations has been described.
The system requires an initial investment of time in performing an adequate diagnostic
waxing, but recoups that time in many clinical and laboratory procedures. The method
has proved a valuable asset in fixed prosthodontic care. The technique can be expanded
and combined with other techniques with a little imagination and artistic bent.

11. Lombardi RE.27 (1977). Factors mediating against excellence in dental esthetics have
been classified and enumerated in this article. A formula for producing unaesthetic

103
prostheses can be hypothesized as follows: Educational de-emphasis + Lack of research +
Technical orientation + Technical tradition + Delegation (abdication) + Poor economics +
Fatigue + Poor office design + Convention + Conditioning + Schemata leads to POOR
DENTAL ESTHETICS. It is postulated that a formula for excellent dental esthetics can
be produced by reversing these factors: Altered schemata + Deconditioning + Altered
convention + adequate office design + Elimination of fatigue + Favorable economics +
Personal participation + Research + Educational emphasis leads to ESTHETIC
EXCELLENCE.

12. Levin EI.24 (1978) A system of esthetic predictions is described that has been used
since antiquity. The naturalness of the system is emphasized by showing examples from
nature and how artists and designers use it. The application of this system to dental
esthetics is facilitated by the description and inclusion of a dental grid for the anterior
esthetic segment.

13. Lundeen HC, Shryock EF, Gibbs CH.28 (1978)

1. A comparison of protrusive and lateral condylar border movement pathways of 163
subjects revealed considerable similarity when the frequency of 80% of the pathways was
compared with the average pathway.

2. A description of the pathways of posterior cusps during lateral contact gliding

movement must consider three simultaneously acting guidance factors: (a) the
nonworking condyle pathway, (b) the amount of Bennett movement or the working-side
condyle displacement, and (c) the anterior guidance or working-side tooth contacts.

3. A Bennett movement of 2.5 to 3.5 mm caused a dramatic flattening of lateral

movement pathways of the molar cusp as seen in the frontal plane. The steepness of
neither the anterior guidance nor the nonworking condylar pathway had much influence
on the molar cusp pathway in the presence of this excessive Bennett movement.

104
4. Viewed in the horizontal plane, excessive Bennett movement contributed to the
greatest potential for collisions of molar cusps during lateral movements. This
phenomenon was more pronounced on the nonworking side.

5. When the Bennett movement was 0.75 mm or less the tracing in the frontal plane
showed that the 40-degree anterior guidance became the dominant influence over molar
cusp lateral movement pathways.

14. Matthews TG.33 (1978) The anatomy of smile is an integral part of dentistry. Its
understanding involves close scrutiny of all elements of the oral region. It is not enough
to establish the size of teeth based on the high and low lip lines, size of the mouth, and a
shade to blend with the age and complexion. To create a harmonious smile the dentist
must maintain or create the normal curvature of lips, proper exposure of the red zone of
the lips, an undistorted philtrum, and undisturbed naso labial grooves. These entities,
maintained in harmony with the exposed teeth, constitute the anatomy of a smile.

15. Vig RG, Brundo GC.54 (1978) A survey has been presented that correlates
measurements of upper lip type, sex, race, and age of dentulous patients with the amount
of exposure of the maxillary and mandibular anterior teeth with the lips gently parted and
in the resting position. Perhaps the most interesting finding was the gradual reduction in
the amount of maxillary central incisor exposure with an increase in age, accompanied by
a gradual increase in the mandibular tooth exposure. The importance of the amount of
mandibular teeth seen in complete dentures has not been sufficiently emphasized in
previous literature.

16. Miller EL, Bodden WR Jr, Jamison HC.36 (1979) This report presents the results of
an original investigation designed to determine (1) the prevalence in the natural dentition
of a maxillary midline located in the exact middle of the mouth using the philtrum as the
most reliable guide and (2) the percentage of people in whom the maxillary and
mandibular midlines precisely coincide with each other. Results indicate that the midline
is situated in the exact middle of the mouth in approximately 70% of people and that the

105
maxillary and mandibular midlines fail to coincide in almost three fourths of the
population.

17. Ortman HR, Tsao DH.41 (1979) The average distance between the most anterior
point of the maxillary central incisors and the most posterior point of the incisive papilla
was 12.454 mm with a standard deviation of 3.867 mm. This distance was measured
when these two points were projected on a plane which was parallel to the reference
plane formed by the tips of three interdental papillae; i.e., the papilla between two central
incisors (A), between the first and second molars on the right side (R), and on the left side
(L). The average error incurred due to inconsistency of the method employed was less
than 3% or less than 0.372 mm for the position of the central incisor. It is believed that
the application of this anatomic relation can provide a reliable point for arranging and
checking the position of the anterior maxillary teeth for complete dentures.

18. Brigante RF.5 (1981) The dentist must maintain a steady rational explanation of the
interaction of all procedures. The patient must be educated in the principles of prosthetic
construction so he can make informed consent decisions. When the relationship becomes
one of people seeking a common satisfying result, the patient will enjoy the important
role of assisting in the choices. Responsibility is identified and fixed in this mutual effort.
The patient is afforded the dignity that is due to those who seek our services. The dentist
must extend himself to make his knowledge, experience and judgment fully available to
the patient.

19. Mavroskoufis F, Ritchie GM.34 (1981) A investigation of 64 Angle Class I, skeletal

Class I dental students showed that the interalar nasal width is a reliable guide for
selecting the mold of anterior teeth, and that the incisive papilla provides a stable
anatomic landmark for arranging the labial surfaces of the central incisors at 10 mm
anterior to the posterior border of the papilla. The mesiodistal width of the set of anterior
teeth (four incisor and the mesial halves of the canines) should be determined by adding 7

106
mm to the patient's nasal width (Fig. 8). The tips of canines on the horizontal plane,
should be set on a line which passes through the posterior border of the incisive papilla
(Fig. 9). The distance between them should equal the patient's nasal width, so that from
the frontal view they would each seem to lie on a perpendicular line drawn from each of
ala of the nose.

20. Albino JE, Tedesco LA.1 (1984) An attempt should be made to empirically study
social and psychological influences on patient expectations and perceptions with respect
to prosthodontic treatment. There may be major differences among patients who are
influenced primarily by family expectations and standards, those influenced by a broader
peer social culture, and those who prefer to remain almost completely dependent on the
judgment of their dentist. Information about the influences on patient expectations and
their decisions about treatment could lead to more accurate predictions in treatment
outcome.

21. McArthur DR.35 (1985) The average width of a natural maxillary central incisor is
8.92 mm. This value is determined from the results of three studies of natural dentitions.
The average width of a mandibular central incisor is 5.5 mm. The average ratio produced
by dividing the average maxillary central incisor width by the average mandibular incisor
width is 1.62. The factor of 1.5 times the width of a mandibular central incisor produces a
maxillary central incisor width that is too narrow. The width of a mandibular central
incisor plus half the width of the mandibular lateral incisor also produces a maxillary
central incisor width that is too narrow. There may be a tendency to undersize the
maxillary prosthetic dentition. The ratio of 1.62 can be used to select the appropriate
width for a missing maxillary central incisor when given the width of the mandibular
central incisor. This ratio of 1.62 is also valuable to verify the dimension of a selected
artificial maxillary central incisor when the patient complains that the tooth is too large. If
substitutions or adjustments are made in the mold, the desired canine-to-canine
measurement produced by the ratio range of 1.3 to 1.38 reported in Parts I and II of this
study should be maintained.

107
22. MacArthur DR.29 (1987)
(1). For all samples, men had larger central incisors than women.
(2). The mean mesio-distal diameter for permanent maxillary central incisors was similar
for both the orthodontic and the mixed dentition samples.
(3). Mesio-distal and incisal tooth wear results in narrower central incisors in older age
groups.
(4). The size of artificial central incisors is generally appropriate for the senior
population.

23. Seluk LW, Brodbelt RH, Walker GF.49 (1987) Dentist and patient preferences are
often used to select replacement teeth in prosthodontics. Face shape compared with
inverted tooth form classifications based on Leon William's work are currently used.
Shapes of teeth and faces have been referred to as square, ovoid or tapered, or some
combination of these. Six patients, three male and three female, were selected as being
classically square, tapered or ovoid in facial form. Three sets of dentures had been made
for each patient with tapering, ovoid and square denture teeth. Using a standardized
photographic technique, full face views with profiles and close-ups of the teeth were
taken. Then from standardized enlarged tracings, key anatomic and derived points were
marked, digitized and computer analysed. The face shapes and inverted tooth forms were
digitized in the same manner. A comparison of tooth moulds versus the actual denture
teeth shows a highly significant difference (P less than 0.001) between set and unset
denture teeth. There is also a significant difference (P less than 0.001) between facial
form and denture teeth using temporal zygomatic and gonial widths for faces, compared
with incisal, contact, and cervical widths for the teeth.

24. Burckett PJ, Christensen LC.3 (1988) The results of this study indicate that it is
difficult to correctly age and sex by using anterior teeth as a guide. The difficulty in
estimating age and sex in dental patients is that they do not always fall in set patterns.
Teeth do tend to darken with age but, this is not always true. Older dentitions sometimes
show minimal wear and some younger dentitions can show moderate to excessive wear.
The position of the maxillary lateral incisors does not always enhance male and female
characteristics. Perhaps the best method to select denture teeth for a patient is to place

108
more consideration on previous dentures and photographs and less on the age and sex of
the patient.

25. Grove HF, Christensen LV.17 (1988) Fifty dentate maxillary casts, obtained from
thirty-four males and sixteen females, were mounted in the three-dimensional co-ordinate
system of a contour meter. A transverse line of reference (x-axis) was drawn through the
distal contact points of the maxillary canines, at a right angle to the y-axis which passed
through the contact points of the maxillary central incisors. Relative to the canine-to-
canine baseline, the locations of the lateral borders of the right and left first primary rugae
were determined. The rugae were distributed on both the anterior and posterior sides of
the baseline, and the anterior and posterior distances from the baseline were on the
average about 1 mm. The age of the subjects, ranging from 12 to 52 years, appeared to be
unrelated to the frequencies of anteriorly and posteriorly positioned rugae. Right and left
first primary rugae, located on the anterior side of the baseline, showed a minute
asymmetry in their topography. By contrast, there was topographical symmetry when the
rugae were located on the posterior side of the baseline.

26. Mack MR.30 (1991) Craniofacial vertical dimension is a more accurate measure of
facial proportion than mere measurement of the mid and lower part of the face.
Craniomaxillary dimension is skeletally determined, whereas facial height of the lower
part of the face is partly dependent on the vertical dimension of occlusion. Alterations in
the vertical dimension of occlusion can dramatically affect the esthetics of the soft facial
tissue. The "Golden Proportion" quantitatively defines ideal measured relationships and
encourages a scientific appreciation of beauty. Faces with deficiencies in lower facial
balance (brachyfacial) often exhibit insufficient height of the occlusal plane. The
scientific literature has suggested a pliability of skeletal muscle allowing for physiologic
variance in vertical facial height. Temporomandibular joint compliance is demonstrated
with elevations in resting muscle length. Facial balance and location of the occlusal
planes are the primary determinants for establishing an appropriate vertical dimension of
occlusion.

109
27. Lau GC, Clark RF.23 (1993) A photographic technique was used to measure
anatomic landmarks located on dental casts. The relationship of the maxillary anterior
teeth to the incisive papilla in a Southern Chinese population living in Hong Kong was
studied. The distances from the labial surface of the central incisors to the midpoint and
the posterior border of the incisive papilla were measured. The area on the incisive
papilla where the intercanine line crossed was noted. The data obtained were compared
with those from previous studies of Caucasians. Results show that there is little difference
between the Southern Chinese in this study and most other ethnic groups. The guidelines
that use the incisive papilla as a reference for the setting of artificial teeth in denture
construction recommended for Caucasians can be applied to Southern Chinese patients.

28. Smukler H, Chaibi M.52 (1997) When the clinical crowns of teeth are dimensionally
inadequate, esthetically and biologically acceptable restoration of these dental units is
difficult. Often an acceptable restoration cannot be accomplished without first surgically
increasing the length of the existing clinical crowns; therefore, successful management
requires an understanding of both the dental and periodontal parameters of treatment.
This report provides further insight into this interdependence by examining the effects of
tooth form on the periodontal morphology and surgical treatment, while relating them to
requirements for esthetically and biologically acceptable full-coverage dental
restorations. This report also explains the role that restoration margin location and
emergence profile play in the maintenance of periodontal and dental symbiosis.

29. Magne P, Magne M, Belser U.31 (1999) With the evolution of adhesive dentistry and
the increasing use of porcelain veneers, single-unit crowns generally are restricted to the
replacement of pre-existing full-coverage crowns and the restoration of nonvital and/or
severely damaged teeth. Porcelain-fused-to-metal restorations are still widely used to
generate single-unit crowns and fixed partial dentures. Collarless metal-ceramic
restorations represent the most successful evolution among efforts to meet maximum
esthetic requirements using porcelain-fused-to-metal restorations. Extended metal
frameworks and opaque aluminous ceramic cores are associated with unpleasant optical
effects in the soft tissues surrounding such restorations. This problem is particularly
evident in the presence of the upper lip, which can generate an "umbrella effect"

110
characterized by gray marginal gingivae and dark interdental papillae. Based on the
concept of the biologic width, a systematic approach is proposed for the elaboration of an
"esthetic width," including: 1) positioning of preparation margins; 2) reduction of the
metal framework; and (c) appropriate marginal design of porcelain-fused-to-metal
restorations. Strategic features of pontics and a specific interdental design are suggested
to compensate for deficient anatomical features of the soft tissue and the edentulous
ridge.

30. Snow SR.54 (1999) With increasing application of cosmetic dental treatment comes
the need for a greater understanding of esthetic principles. Scientific analysis of beautiful
smiles has revealed repeatable, objective principles that can be systematically applied to
evaluate and improve dental esthetics in predictable ways. Symmetry across the midline,
anterior or central dominance, and regressive proportion are three composition elements
required to create utility and esthetics in a smile. The Golden Proportion has been
suggested as one possible mathematic analysis tool for assessing dominance and
proportion in the frontal view of the arrangement of maxillary teeth. It has proven to be
controversial in developing esthetically beautiful smiles and cumbersome for evaluating
symmetry.
CLINICAL SIGNIFICANCE: This article considers a bilateral analysis of apparent
individual tooth width as a percentage of the total apparent width of the anterior segment
and proposes the concept of the Golden Percentage as a more useful application in
diagnosing and developing symmetry, dominance, and proportion for esthetically
pleasing smiles.

31. Rosenstiel SF, Ward DH, Rashid RG.46 (2000)

PURPOSE: This study aimed to determine dentists' esthetic preferences of the maxillary
anterior teeth as influenced by different proportions. The goal was to link choices to
demographic data as to the experience, gender, and training of the dentist.

METHOD AND MATERIALS: Computer-manipulated images of the 6 maxillary

anterior teeth were generated from a single image and assigned to 5 tooth-height groups

111
(very short, short, normal height, tall, and very tall). For each group, 4 images were
generated by manipulating the relative proportion of the central incisors, lateral incisors,
and canines according to the proportions 62% (or "golden proportion"), 70%, 80%, and
"normal" or not further altered. The images were randomly ordered on a web page that
contained a form asking for demographic data and fields asking for a ranking of the
images. Dentists were asked via e-mail to visit the web page and complete the survey.
The responses were tabulated and analyzed with repeated measures logistic regression
with the alpha at 0.05. A subset of North American respondents was chosen for further
analysis.

RESULTS: A total of 549 valid responses were received and analyzed from dentists in 38
countries. There were statistically significant differences in all groups for the variables of
proportion, group (tooth height), and their interaction. The 80% proportion was judged
best for the Very Short and Short groups. Three of the choices were almost equally
picked for the Normal Height and Tall groups, and the golden proportion was judged best
for the Very Tall group. The variables of year of graduation, gender, professional activity,
generalist or specialist, or number of patients were not significantly correlated with the
choices for the North American respondents.

CONCLUSIONS: Dentists preferred the 80 percent proportion when viewing short or

very short teeth and the golden proportion when viewing very tall teeth. Golden
proportion was worst for normal height or shorter teeth and the 80% proportion for tall or
very tall teeth. They picked no clear-cut best for normal height or tall teeth, and their
choices could not be predicted based on gender, specialist training, experience, or patient
load.

32. Gillet D, Miquel JL, Jeannel A.14 (2002) The aim of this study was to evaluate the
importance of the dental aesthetic for the patients, the dental surgeon and the dental
teachers by the study of the consultation reason, the complaints, the post-university
congress program, the practical program of the dental students and the programs of the
IADR congress. It appears that in odontology, patients ask strongly for aesthetic care, in

112
consultation and litigation. The content of congress and professional literature shows that
dental surgeons answer to that request. Only the practical teaching was a bit less but it
was recently modify. The research workers are also very interesting for aesthetic care.

33. Jameson WS.20 (2002) The dynesthetic and dentogenic concept, when applied,
provides a more natural, harmonious prosthesis, which not only is desired by patients, but
also is a quality of care they deserve. Outstanding esthetics can be achieved by simple
guidelines, using tooth molds specifically sculpted for males and females, arranging
prosthetic teeth to correspond with personality and age and sculpting the matrix (visible
denture base) with more natural contours. There is no reason for edentulous individuals to
be provided with care of any less quality than that available with other procedures, such
as crowns, bridges, veneers, or implant restorations. Providing this upscale product can be
rewarding and satisfying to patient and operator alike. This concept produces superior
results no matter what posterior occlusal scheme is employed but, in the opinion of the
author, works best when used in conjunction with a noninterceptive linear occlusion
approach (not to be confused with lingualized occlusion), which precludes anterior
contact.
CLINICAL SIGNIFICANCE: Dentogenics provides an approach to esthetics in
prosthodontics that enables the dentist to create a restoration in harmony with the patient's
objective personality. This concept considers gender, age, and personality to restore the
patient's dignity and unique individuality that has been missing in far too many
prostheses.

34. Naylor CK.37 (2002) It is sometimes difficult to identify esthetic problems let alone
pre-visualize an esthetic end-result. The Esthetic Grid Analysis is a system for analyzing
the basic problems that detract from the concept of an attractive smile. A photograph is
taken of the anterior teeth with the lips retracted. The upper and lower frame of the
photograph is aligned parallel with the interpupillary line, assuming that the interpupillary
line is parallel with the horizon. Where this is not the case, the vertical margins of the
photograph are aligned parallel with the facial midline. Through orienting the photograph
to the facial guidelines and incorporating the idealized positions of the incisal plane,
highest lipline, midline axis, and proportionate contact areas, a grid is formed. The grid

113
built from these components provides a method of demonstrating deviations from an
esthetic arrangement of anterior teeth.
CLINICAL SIGNIFICANCE: Integrating facial guidelines with the dental composition
using a grid highlights deviations from the ideal. It thereby assists in the treatment
planning process by communicating esthetic problems to the patient, laboratory
personnel, and other specialists.

35. Schneider RL, Curtis ER, Clancy JM.48 (2002)

STATEMENT OF PROBLEM: Fracture of acrylic resin prosthetic teeth from acrylic
resin denture bases can be a problem for some patients. The optimal combination of
acrylic resin denture tooth, denture base material, and processing method is not known.
Purpose. The objective of this study was to compare the tensile bond strengths of heat-
and microwave-polymerized acrylic resins among 4 types of acrylic resin denture teeth.
MATERIAL AND METHODS: Heat-polymerized (Lucitone 199) and microwave-
polymerized (Acron MC) acrylic resins were used. Four types of acrylic resin denture
teeth (IPN, SLM, Vitapan, and SR-Orthotyp-PE) were milled to a fixed diameter
according to ADA specification no. 15. Ten specimens of each tooth type were processed
to each of the denture base materials according to the manufacturers' instructions. Ten
additional resin control specimens without teeth also were fabricated. Specimens were
thermocycled and tested for strength until fracture with a custom alignment device. Data
were analyzed with analysis of variance and Duncan's multiple range tests. A scanning
electron microscope was used to identify adhesive and cohesive failures within debonded
specimens.
RESULTS: The mean force required to fracture the specimens ranged from 5.3 +/- 3.01
to 21.6 +/- 5.2 MPa for the microwave-polymerized base and 11.2 +/- 3.0 to 39.1 +/- 5.1
MPa for the heat-polymerized base. The most common failure was cohesive within the
denture tooth. With each base material, Orthotyp and IPN teeth exhibited the highest
bond strengths; SLM and Orthotyp bond strengths were similar. In general, heat-
polymerized groups failed cohesively within the denture base resin or the tooth, and
microwave-polymerized groups failed adhesively at either the ridge lap or occlusal
surface of the denture tooth.

114
CONCLUSION: Within the limitations of this study, the results suggest that the type of
denture base material and denture tooth selected for use may influence the tensile bond
strength of the tooth to the base. Selection of more compatible combinations of base and
resin teeth may reduce the number of prosthesis fractures and resultant repairs.

36. Burns DR, Beck DA, Nelson SK.4 (2003) One goal of the American Academy of
Fixed Prosthodontics is regularly to publish comprehensive literature reviews on selected
topics germane to the discipline of fixed prosthodontics. The following report is the result
of this goal and focuses on provisional fixed prosthodontic treatment. Major subtopics
include materials science and clinical considerations involving natural teeth and dental
implants. The interrelationship between provisional and definitive fixed prosthodontic
treatment is multifaceted and significant. Provisional therapy involves numerous
materials and techniques that require special knowledge and technical experience. In this
analysis, technical, clinical, and investigational articles are detailed and presented as a
comprehensive literature review to provide contemporary guidelines. Referenced
publications were found by conducting a Medline search and were limited to peer-
reviewed, English-language articles published from 1970 to the present. Materials used
with provisional treatment are discussed in terms of clinical selection and the influence of
their physical properties on treatment outcome. Specific product names and
manufacturers are included in this report only when they are cited in the original
referenced publications.

37. Christensen GJ.8 (2003) Crowns and fixed prostheses are well-proven, accepted and
routinely used restorations. However, they occasionally come loose from tooth
preparations. Many things can cause these failures. In this article, I have discussed the
following reasons for lack of adequate retention of crowns and fixed prostheses:
inadequate tooth preparation; too much trust in dentin bonding agents and lack of
adequate tooth buildup; tooth preparations that lack irregularities; improper selection of
cements; and lack of postoperative occlusal adjustment.

115
38. Frindel F.13(2003) The present study aims at establishing elements for diagnosis and
construction of a harmonious, balanced, desirable and durably young smile. Once the
importance of a harmonious smile in today's society has been studied, smile is analyzed
under two aspects. One considers it in its own unitary structure, the other in its living
immediate environment: the face. Sixteen key rules have been defined to characterize and
analyze it. Those various "keys of smile" will enable the practitioner to construct it in
positioning the maxillary teeth in a facial balance, thus meeting the criteria of esthetics
and appeal so much wanted by our patients. Taking into account the criterion of general
aging of the face, the smiles thus realized will remain young for a longer period of time.
Three principles of analysis have been used to achieve this task: the observation in
"dynamic" situation (as opposed to a "static" frozen study), the reference to particular
measurements for each case (as opposed to measurements refering to statistics tables),
and the evaluation of the interlabial space at rest of the case considered. This leads to the
definition of the measurement of the "golden section dynamic smile" (G.S.D.S.) and a
reminder of the measurement of "the constant of ideal smile" (C.I.S.). Adorned with such
smiles, our patients will benefit from a real feeling of well-being which they will
communicate to their circle of friends and acquaintances for their greatest delight.

39. Olsson KG, Furst B, Andersson B, Carlsson GE.40 (2003)

PURPOSE: The purpose of this study was to evaluate the long-term outcome of In-Ceram
Alumina fixed partial dentures (FPD) performed in a general dental practice from 1992 to
1996.
MATERIALS AND METHODS: The study was conducted as a retrospective assessment
of up to 9 years of patient records and a clinical follow-up examination of patients treated
with In-Ceram Alumina FPDs. In 37 patients, 42 FPDs had been inserted during the
selected period. After randomized selection, 16 patients with 18 FPDs were examined
clinically. The most common restorations comprised two and three units. Cantilever
extensions were present on 64% of the FPDs. Sixty-two percent of the FPDs extended
into the posterior region.

116
RESULTS: The mean time in function for the 42 FPDs was 76 months (range 2 to 110
months), with 86% being followed for > 5 years. No adverse effects to either periodontal
or pulpal tissues were recorded. The technical quality was very good, and patient
satisfaction very high. Five FPDs fractured during the observation period, resulting in a
total failure rate of 12%. Two of these FPDs fractured as a consequence of external
trauma. Excluding these, the total survival rate during the observation period was 93%.
Cumulative survival rate according to life table analysis was 93% after 5 years and 83%
after 10 years.
CONCLUSION: The results suggest that the In-Ceram Alumina short-span FPD is a
viable prosthetic alternative.

40. Donovan TE, Chee WW.10 (2004) The contemporary restorative dentist has a host of
impression materials available for making impressions in fixed prosthodontics,implant
dentistry, and operative dentistry. With proper material selection and manipulation,
accurate impressions can be obtained for fabrication of tooth- and implant-supported
restorations. This article outlines the ideal properties of impression materials and explains
the importance of critical manipulative variables. Available impression materials are
analyzed relative to these variables, and several "specialized" impression techniques are
described. Special attention is paid to polyvinyl siloxane impression materials because
they have become the most widely used impression material in restorative dentistry.

41. Flores-Mir C, Silva E, Barriga MI, Lagravere MO. 12(2004)

OBJECTIVE: To compare the aesthetic perception of different anterior visible occlusions
in different facial and dental views (frontal view, lower facial third view and dental view)
by lay persons.
DESIGN: Cross-sectional survey, Lima, Peru, 2002.
SUBJECTS: The different views were rated by 91 randomly selected adult lay persons.
MAIN OUTCOME MEASUREMENT: Visual Analogue Scale (VAS) ratings of
aesthetic perception of the views.
RESULTS: Anterior visible occlusion, photographed subject and view (p<0.001) had a
significant effect on the aesthetic ratings. Also gender (p=0.001) and the interaction

117
between gender and level of education (p=0.046) had a significant effect over the
aesthetic rating.
CONCLUSIONS: A lay panel perceived that the aesthetic impact of the visible anterior
occlusion was greater in a dental view compared with a full facial view. The anterior
visible occlusion, photographed subject, view type are factors, which influence the
aesthetic perception of smiles. In addition, gender and level of education had an
influence.

42. Ibbetson R.19 (2004) Many dental practitioners do not use adhesive bridges because
of concerns over high failure rates. Techniques for these restorations should be based on
the fundamental principles of bridge design which require rigid, accurately fitting
frameworks and careful control of the occlusion. The abutments generally require little if
any tooth preparation. Greater security will result from more extensive coverage of
abutment teeth: the routine use of relative axial tooth movement is a predictable method
for creating the space that this approach requires.

43. Neves FD, Mendonca G, Fernandes Neto AJ.38 (2004)

The lip line and lip support influence esthetics and selection of implant-supported
prosthetic designs for maxillary edentulous patients. This article describes a procedure to
analyze the influence of lip line and lip support on the esthetics of an existing maxillary
complete denture, revealing potential limitations when planning a fixed implant-
supported prosthesis.

44. Rifkin R, McLaren E.45 (2004) Innovations in material science and clinical
techniques have expanded the number of treatment options available for nonvital anterior
teeth. These options include the use of composite to fill the access opening with no
additional treatment, crown placement, orthodontic extrusion, crown lengthening with or
without orthodontic extrusion, dowel restorations with crown placement, and fixed bridge
or implant therapy when extraction is necessary. Clinicians need to understand the
benefits and limitations of each option in order to provide their patients with optimum
function and aesthetics. Using case presentations, this article describes predictable

118
approaches for the diagnosis, treatment planning, and restoration or replacement of
endodontically treated teeth in the anterior region.

45. Simon J.51 (2004) Many dental patients are unhappy with their smile but believe a
beautiful smile is outside their budget. The first step is to listen to the patient in order to
understand what his or her primary concerns are. The second step is to examine carefully
and analyze the case to develop a treatment plan that will fulfill as much as possible of
the patient's desires within the context of his or her constraints (financial or otherwise).
Also, remember that dentistry doesn't end when the last veneer is placed or the last bill is
paid. The final step is to maintain a strong relationship with your patients to ensure good
oral hygiene and restorations that are as long-lasting as they are beautiful.

119