Smile design

Smile design

TABLE OF CONTENTS

 INTRODUCTION

 DEFINITIONS

 PHYSICAL ATTRIBUTES OF THE ELEMENTS OF THE DENTO-FACIAL

COMPOSITION

 PERCEPTUAL ASPECTS – THE ART OF ILLUSION

 ESTHETIC DIAGNOSIS AND TREATMENT PLANNING

 ROLE OF TECHNOLOGY IN CHANGING SMILE

 ESTHETIC TREATMENT PLANNING AND SEQUENCING

 COLOR

 DENTAL BLEACHING

 ESTHETICS WITH COMPOSITES

 ESTHETICS WITH CERAMICS

 IMPLANT – ESTHETICS

 PERIO – ESTHETICS

 ORTHO – ESTHETICS

 REVIEW OF LITERATURE

 CONCLUSION

 REFERANCES

INTRODUCTION

In our modern competitive society, a pleasing appearance often means the difference between

success and failure in both our personal and professional lives. Scottish physiologist Charles bell

(1774-1842) was quoted as remarking that the thought is to the word that the feeling is to the

facial expression. He pointed out in 1806 that a smile could convey a thousand different

meanings, yet it is the most easily recognized expression. And because the mouth is one of the

focal points of the face , it should come as no surprise that the smile plays a major role in how

we perceive ourselves, as well as in the impressions 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. An attractive or pleasing smile clearly enhances the acceptance of the
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individual in the society where he belongs and the character of the smile influences the

attractiveness and the personality of the individual.

CLASSIFICATION OF SMILE(Solomon E.G.R.)

1) Depending on the nature of labial mucous membrane

a) Papilla smile

b) Gingival smile

c) Mucosa smile

2) Dependant on the lip component

a) Straight smile

b) Convex smile

c) Concave smile

DEFINITIONS:

Glossary of Prosthodontic terms January 1999.

Esthetics

1. Pertaining to the study of beauty and the sense of beautiful. Descriptive of a specific

creation that results from such study; objectifies beauty and attractiveness and elicit pleasure.

2.

Pertaining to sensation

Esthetic reshaping
Modification of the surfaces of teeth to improve appearance

Esthetics (adj. 1798)

1. The branch of philosophy dealing with beauty.

In dentistry, the theory and philosophy that deal with beauty and beautiful, esp. with respect to

the appearance of a dental restorations, as achieved by its contour and color.

Those subjective and objective elements and principles underlying the beauty and attractiveness

of an object, design or principle

Dental Esthetics

The application of the principles of esthetics to the natural or artificial teeth and restorations

(GPT 1999)

Esthetic Dentistry

Can be defined as the art and science of dentistry applied to create or enhance beauty of an

individual within functional and physiological limits. (Ratnadeep Patil)

Cosmetic dentistry: is application of the principles of esthetics and certain illusionary

principles, performed to signify or enhance beauty of an individual to suit the role he has to play

in his day-to-day life or otherwise. (Ratnadeep Patil)

Smile designing

Is a process whereby the complete oral hard and soft tissues are studied and evaluated and

certain changes are made which will have a positive influence on the overall esthetics of the face.

These changes are governed by the principles of esthetic dentistry. Hence, a good smile design

Would naturally and effortlessly blend with the rest of the face to provide an esthetic and

functional complex .
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“A well designed smile is a product of consolidated efforts accomplished by accurate

diagnosis, methodical treatment planning, use of advanced materials and contemporary

techniques rendered by the skilled dentist”.

PHYSICAL ATTRIBUTES OF THE ELEMENTS OF THE DENTO-FACIAL

COMPOSITION

The artistic parameters to be considered for essential beauty and those which are subtly present

in natural beauty form the fundamental principles of esthetics. Understanding these artistic

parameters of beauty and co-relaing them to the dento-facial complex will enable the dentist to

appropriately scale esthetics in any dento-facial composition.

Composition means the act of combining elements or parts to form a whole. There are various

physical attributes of the elements of a composition that impart the esthetic value. The various

physical attributes of the elements of a composition are:

Contrast:

It is that factor which makes the various elements of a composition visible. The eye can

differentiate the parts of an object due contrast of colors,lines, patterns, textures, etc. The

relationship between the different parts of the face (facial), the teeth and the gums (dental) made

visible by contrast constitutes the dento-facial composition.

Unity or oneness: “It gives different elements of the composition the effect of a whole”. Unity

can either be static, when repeated shapes or designs are seen as in inanimate things, like the

composition of crystals; or dynamic and changing as in living beings. Unity between different

parts of the face, and teeth is essential to give the effect of oneness to the dento-facial

composition.
Cohesive and segregate forces:

Any element which tends to unify a composition is a cohesive force. Segregative forces are those

elements which break the monotony of the composition. Naturalness has combination of

cohesive and segregative forces. A proper mix of segregative and cohesive forces makes dento

facial composition dynamic.

Symmetry: It is the mirror image of one side of face to the other side of face.

It can be

horiregularity of arrangement of forms either from left to right as in horizontal symmetry, or

from a central point to either side like a mirror image as in radiating symmetry. The horizontal

symmetry looks repetitive and uninteresting while the radiating symmetry looks dynamic and

interesting. In a dento-facial composition radiating symmetry of the teeth is more esthetically

appealing and is associated with youthfulness while horizontal symmetry is less appealing and is

associated with aging.

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Proportion: To be able to give a certain mathematical representation of beauty for numerically

expressing the relationship of the various units that combine to make a composition, the term

proportion is used.

The relationship of the various units which are different from each other in a composition but are

associated with each other through a certain repetitive mathematical factor is the repeated ratio.

The proportion between the various elements of a harmonious composition, in which the

cohesive and segregative forces are equally balanced,and whichhas its various units in an

esthetically appealing respective proportion to each other is the golden proportion

Dominance: It exists when a strong centralized structure is surrounded by well-demarcated,

characterized structures. In a dento-facial composition it creates immaculate unity leading to a

harmonious compaosition. The absence of dominance makes the composition weak. Color, shape

and size are the factors which can control dominance.

Balance: It is achieved when there is an exact equilibrium between the forces present on either

side of the fulcrum in a composition. In dentistry this implies the balance of the elements in

relation to the midline. If any elements are imbalance on one side then, to create a visual balance

either these elements are moved towards the midline or are counter-balanced with opposite
elements to regain the balance. In balance the weight of the elements far away from the fulcrum

grows in importance.

Visual tension is the tension brought about by the presence of certain elements that cause an

imbalance in the given composition. If the presence of these factors is closer to the fulcrum, the

effect of the tension into the fulcrum,the effective the tension induced is more magnified as

against their presence further from the fulcrum. A distally inclined lateral incisor on one side is

compensated by a more mesial inclination of the first premolar on the opposite side to reduce the

effective visual tension. These variations are naturally found in dentitions explaining the reason

why sometimes irregularities in inclinations still produce pleasant smiles.

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.

These are the factors of esthetic compositions and they help the dentist in determining tooth

display, size, arrangement and alignment during the diagnosis and treatment phase.

The dento-facial frame constitutes the teeth and gingiva related to the lips and then to the entire

face. The oral frame is determined by the anatomy and mobility of the tissues when in function

surrounding the teeth and gingiva .The exposed portion of the oral elements i.e. teeth and gums

within the oral frame during a smile is called the smile window.
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The anatomical elements of the face and the biological elements that include the functional and

phonetic elements, provide the reference frames, guidelines and points. These elements help the

dentist to achieve a general sense of orientation and diagnosis.

References can be classified as horizontal references, vertical references, sagital references and

phonetic references.

Horizontal references: The horizontal perspective of the face is provided by the interpupillary

line the commissural line.

The inter-pupillary line helps to evaluate the orientation of the incisal plane, the gingival

margins and the maxilla. An imaginary horizontal line through the incisal plane and the gingival

margins should be visibly parallel to the inter-pupillary line. This helps to diagnose any

asymmetry in the tooth position or gingival location. When an imaginary line is drawn across the

gingival margins, it may not be parallel to the inter-pupillary line indicating a certain degree of

canting of the maxilla.

Certain amount of canting of maxilla is considered normal and in such cases mild correction of

the gingival margins can achieve a pleasing symmetry Severe canting may require an inter-

disciplinary approach involving surgical repositioning of the maxilla.

Vertical references: The facial midline serves to evaluate the location and axis of the dental

midline and the medio-lateral discrepancies in tooth position.The inter-pupillary line and the

facial midline emphasize the ‘T’ effect in a pleasing face. The dental midline, if perpendicular to

the inter-pupillary line and coinciding with the bridge of the nose and the philtrum, produces an

attractive orientation of the smile.

Axial inclination is the direction of the anterior teeth in relation to the central midline and

becomes progressively more pronounced from the central incisor to the canine. There is a

definite mesial inclination to all the anterior teeth related to the midline. The axes of the

premolars and the first molar on either side also show mesial inclination in relation to the

midline.

The perception of tooth inclination can be viewed from the frontal aspect around the central

vertical midline, which acts like a fulcrum around which axial inclination of teeth on either side

exhibit a phenomenon of balance of lines Natural smiles show a deviation from these standard

axial inclination. Deviations in axial inclination cause a visual tension when beyond the point of

equilibrium

Sagittal references: Soft tissue analysis at a standardized position helps in studying the profile of

an individual. The contours of the upper and lower lip support is determined by the position of

the anterior teeth and can be used as a guide for the placement of teeth when planning

restorations. The lip protrusion, the amount of prominence of chin, recession or prominence of

the nose and its degree, all help in profile analysis for diagnosis and treatment planing.

The E-line or esthetic line is an imaginary line connecting the tip of the nose to the most

prominent portion of the chin on the profile, ideally the upper lip is 1-2 mm behind and the lower

lip 2-3mm behind the E-line. Any change in the position of the E-line indicates the abnormality

in the upper or lower lip position.

The main support of the upper lip is contributed by the gingival two thirds of the maxillary

central incisors rather than the incisal one third According to studies by Maritato and Douglas the

lip support is a better guide of tooth position than of incisal edge position.
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The relationship of the maxillary incisl edges to the lower lip is a guide for the placement of the

incisal edge position and length. The pronunciation of the ‘F’ and ‘V’consonants helps determine

the position of the incisal edges. On pronouncing ‘F’ and ‘V’ the incisal edges should make a

definite contact at the inner vermilion border of the lower lip Thus the position of the incisal

third of the maxillary central incisor can be determind.

Phonetic references: Phonetics play a part in determining maxillary central incisor design and

position. ‘F’ and ‘V’ sounds are used to determine the tilt of the incisal third of the maxillary

central incisors and their length. The ‘M’ sound is used to achieve relaxed rest position and

repeated at slow intervals can help evaluate the incisal display at rest position ‘S’ or ‘Z’ sounds

determine the vertical dimension of speech.. Its pronunciation makes the maxillary and the

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 near contact for the ‘S’ sound.

Smile elements: The extent of the smile is outlined by the curvature of the upper and lower lip

and the position of the angle of the mouth, and it determines the degree of exposure, both in the

anterior and posterior teeth, gingiva as well as the width of the buccal corridor

Smiles can be classified as passive, active (moderate) and laugh. In a passive smile the lips are

parted slightly away from the rest position expressing content, passion, desire, surprise, etc. In an

active smile the lips move to a significant extent away from the rest position displaying more

teeth and even gums, expressing joy, welcome, happiness, etc. Laugh is an instant fluctuation

from an active smile position where the facial muscles instantly act leading to maximum
exposure of the teeth and gums. Humorous and funny situations usually lead to such an

expression.

Lip and lip lines: The length, the curvature and the shape of the lips significantly influence the

amount of tooth exposure during rest and in function.

A prominent tooth display is associated with a youthful smile and most patients would like to

seek the benefit of the same. Some researchers demonstrated that the average maxillary incisor

display with the lips at rest is 1.91mm in men and 3.40 mm in Women Patient’s with short upper

lips and younger patients generally display more maxillary tooth structure which may be up to

3.65mm.

Upper lip line helps to evaluate the length of the maxillary incisor exposed at rest and during

smile and the vertical position of the gingival margins during smile.

The upper lip line can be classified as low, medium or high depending upon the amount of tooth

or gingival display that is available at rest of during a moderate smile. The gingival margins may

be displayed in high lip line cases. The most apical position of the gingiva over the facial aspect

of the maxillary central incisor and canine is slightly distal to the long axis of the tooth while in

the maxillary lateral incisor it is at the long axis of the tooth. This is called the gingival zenith.

Whenever a patient displays the gingival margins easily on smiling or speaking, a definite pattern

of the gingival display can be recorded. This pattern can be either esthetic or unesthetic A smile

can be termed “toothy” if more than 6mm of incisal display is seen at rest position or “gummy”

if more than 3mm of gingival tissues are displayed in moderate smile.

Lower lip line helps to evaluate the buccolingual position of the incisal edge of the maxillary

incisors and the curvature of the incisal plane

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Smile line: It is an imaginary line passing through the incisal edges of the upper anterior teeth.

The smile line usually coincides or runs parallel to the inner vermilion border of the lower lip. In

a youthful smile the incisal edges of the central incisors and canines are aligned on a convexity

and are linger than the lateral incisors, incisal embrasures gradually deepen from central incisor

to the canine, giving the appearance of the wings of a gull. Thus the incisal plane is said to have

a gull-wing apperance when the incisal edges of the central incisors and canines are aligned on a

convexity the incisal plane is convex. Reduced incisal embrsures and leveling of the gull-wing

effect as in a straight smile line is associated with aging.

Negative space: Negative space is a dark space appearing between the jaws and the mouth

opening either at the corner of the mouth of around the buccal aspect of the posterior teeth during

active smile and laugh.The lateral negative space exists between the labial surface of maxillary

teeth and the corner of the mouth while the buccal negative spaces appear in the buccal vestibule

on either side of the buccal aspect of posterior teeth.

Obliteration of these essential spaces by dental elements like bulky canines, wide arches or over-

contoured restorations can lead to an unattractive smile.

Excessive negative space seen in cases of missing premolars orA palatally placed posteriors and

a constricted arch also appear unesthetic.

Progressive abating in a dental composition: When similar structures are aligned in an arch

form one after the other, they appear to progressively abate in size from the nearest to the

farthest. This gives an illusion of depth.

 The essential requirement of the front to back progression in dental composition is the

alignment of the contour of the labial and surface at the incisal third, middle third and the

gingival third of successive teeth in the arch. The incisal mesio-buccal inclines should be well

aligned to give a smooth progression from tooth to tooth. The buccal and lateral negative space

progressively reduces the illumination on teeth to enhance the front to back abating effect. The

presence of poorly shaped teeth, differences in axial inclinations, tooth length discrepancies,

discolorations, gingival disharmonies etc. can lead to a visual tension resulting in a disruption of

the front to back progression.

Proportion

When mathematics is applied to the study of ideal tooth form, a numerical relationship is

established within a single tooth form (ideal proportion) and also between a series of teeth in the

arch (relative proportion). The position of the tooth in the arch, the relationship between the

width, the length and the face of the tooth can also be numerically established in relation with

certain anatomic landmarks.

Gold Proportion is expressed in numerical form and applied by classical mathematicians such as

Euclid and Pythagoras in pursuit of universal divine harmony and balance. It has been applied to

a lot of ancient Greek and Egyptian architecture and may be expressed as the ratio 1.618:1.

If the ratio is applied to the smile made up of the central, lateral incisor and the mesial

half of the canine, it shows that the central incisor is 62% wider than the lateral incisor which in

turn is 62% wider than the visible portion of the canine which is the mesial half, when viewed

from the front.

Application of sizing the central incisors from certain facial measurements is known as the 1 to

16 theory, whereby the height of an ideal maxillary central incisor from the incisal edge to the
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th
gingival crest is 1/16 of the distance from the inferior border of the chin to the inter papillary

th
line. The same tooth width can be measured from the mesial to distal contact areas and is 1/16

of the distance measured from either zygomatic prominence through an imaginary facial midline.

Once the size for the central incisor is determined it is essential to design its outline form. The

facial harmony method can be applied to relate the tooth form to the facial form. Various facial

shapes are identified and descriptions such as avoid, square, tapered and combinations of these

are used The same shape when inverted can be applied to the central incisor design. This shape

acts as guideline for the outline forms of other maxillary teeth.

In an attempt to determine the original anterior tooth placement on the ridge, the position of the

incisive papilla is considered as an important land mark as it position does not alter even after

bone resportion of the anterior ridge. The distance between the posterior border of the papilla to

the outer labial surface of the central incisor averages to about 12.5mm with a variation of

approximately 3.8mm. The end of the first palatal ruga is located 1.5 mm to 2mmm from the

lingual surface of the canine. Many dentists have also recorded the averages distance between

the base of the sulcus and the tip of the maxillary incisor. This distance is measured 22mm. This

helps the dentist to determine the tooth position in the vertical plane.

Symmetry

For harmony, certain symmetries are essential while certain asymmetries are acceptable.

Harmonious facial features should be more symmetrical close to the facial mid line and can be

more asymmetrical away from the facial midline.

Pleasing Smile
 A naturally attractive smile that evokes a feeling of beauty or harmony and complements

the personality of the bearer is termed as a pleasing smile.

The natural pleasing smile may not necessarily comply with all rules of sy

mmetry or golden proportion or may not exhibit perfect balance without irregularity of shape.

However, the composition is esthetically appealing with unity within its various elements.

Smile Dominance: Different facial features stand out differently in the eyes of every beholder. In

certain cases, the most predominantly striking features of a face are the smile; these are the

“Dominant Smiles”.

The distinguishing characteristics observed in people with pleasant smile dominance that

can be used as a guideline for creating the same are:

 The maxillary central incisors exhibit a strong presence by their size and form reflecting

the personality of the individual.

 The maxillary lateral incisors and the canines complement the cement incisor in terms of

proper shape and form.

 Although numerically all proportions of the anterior teeth do not follow the rule of golden

proportion, the teeth are so placed that they appear in suitable proportions with each other.

 Smile recurring ratios are observed in the teeth from the central incisor to the premolar.

 Well co-ordinated movements of the lips with the other peri-oral musculature and

corresponding harmonious facial expressions, contribute to the pleasant face during smile.

 The complexion and texture on the face contrast with the lip color, gingival and the teeth

leading to a distinct demarcation between the oral and the facial frame.
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PERCEPTUAL ASPECTS – THE ART OF ILLUSION

Illusion is a figment of imagination where a perception of an object is created.

Fundamentals and Principles

The art of creating illusions consists of changing perception, to cause an object to appear

different from what it actually is. Teeth can be made to appear smaller, larger, wider, narrower,

shorter, longer, younger, older, masculine or feminine.

One is subjected to light the most fundamental objects exhibits two dimensions, that is,

length and width. True natural light is multi-directional and on striking the surface of the object,

also reveals texture and shadows, this adds the third life like dimension of depth.

Illusion works on two basic principles which are the principle of illumination and the principle of

light. The most important of these is the perception that light approaches and dark recedes. This

is termed as the ‘Principle of Illumination”. The second artistic predilection of great

importance in dentistry is the use of horizontal and vertical lines and ridges. Horizontal lines

make the object appear wider and vertical lines make the object appear longer. This is termed as

the “Principle of Line”.

The artistic predilection exhibited in the principle of illumination can be maintained to change

the size, shape and the overall form of the tooth through illusions.

Law of the face. The face of a tooth is that area on the facial surface on both anterior and

posterior teeth that is bound by the transitional line angles as viewed from the facial i.e. labial or

buccal aspect. These transitional line angles mark the transition from the facial surface to the

mesial, distal, and cervical and incisal surfaces. The tooth surface slopes lingually in the mesial
and distal region while it slopes cervically from the line angles towards the root surface.

Whenever there is no transitional line angle demarcating the incisal portion of the facial surface,

the face is bound by the incisal edge or the occlusal tip.

Shadows created as light strikes the facial surface of the tooth begin at the transitional line

angles, these shadows delineate the boundaries of the facial form. Thus the apparent face is that

portion of the face that is visible to the observer from any single view. When maxillary anterior

teeth are viewed from the front only the mesial half of the canine is visible however the entire

incisor face is visible.

The law of the face implies making dissimilar teeth appear similar by making the apparent faces

equal. The apparent face should be manipulated, not the actual face. This is more important in

the canines and the posteriors as the ‘apparent face’. The transitional line angles are relocated so

that the apparent faces look equal, however this results in dissimilar areas outside the transitional

line angles.

Similar faces produced attract light and appear high lighted while the dissimilar areas that

are in a shadow appear to recede.

When the transitional line angles cannot be repositioned on a restoration, then the portion

of the tooth can be stained darker to create an illusion that the transition line angle has been

moved.

Cosmetic contouring

Cosmetic contouring by definition is the reshaping of natural teeth to make them

esthetically pleasing.

In natural dentitions, variations seen in tooth shape and size some times violate the

acceptable width to length ratios as well as the golden proportion. Minor adjustments in
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contours to change the perception of these proportions increases the esthetic acceptability to a

great extent. It is indicated for giving a pleasing appearance to fractured, chipped, extruded,

malformed or over lapped teeth .

The procedure is contra indicated in hypersensitive teeth, teeth with thin or defective enamel

formation or large pulp chambers.

The upper lip line should be used as a reference to see how much tooth is visible when

the patient smiles. The lower lip line will help to create a pleasing smile line. Tooth visibility

with lips at rest, when the patient talks or smiles should also be assessed. The dentist should view

the patient in sitting and standing positions.

Procedure

The procedure involves minimum tooth reduction confined to enamel. Changes on the

tooth surface of the related tooth are carried out by working on the transitional line angels, height

of contour, incisal and facial embrasures and adjusting incisal edge and angels. Finishing disks

are used to open incisal embrasures and the reshaped teeth are then thoroughly polished with a

fine grit diamond paste and application of fluoride gel or foam is recommended to minimize any

chances of postoperative sensitivity.

ESTHETIC DIAGNOSIS AND TREATMENT PLANNING

Total Smile Analysis

Total smile analysis is a cumulative inference analysis, drawn by interpreting and integrating

various analysis like a visual, space profile and computer analysis after performing the

preliminary analysis.

Space Analysis

It 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 to compare it with space present in the arch. This determines whether the space

available for restorations and natural teeth is less or more than required.

Disproportionate spaces may be due to discrepancies in jaw and tooth size, malformed

teeth, missing teeth, mal-aligned teeth etc. The space analysis will provide a guideline or a frame

work within which the esthetic dentist has to plan each restoration.

Corrections of labio-lingual inclinations and rotations of the teeth by restorative procedures will

result in a change in the width space ratio due to the change of angulation involved.

It may not be possible to match all teeth on either side of the midline due to space or

morphological constraints, but in order to preference they should be matched as far as possible

starting from the midline and proceeding towards the canines. Symmetry and dominance of the

central incisors being an important element of the pleasing smile should not be compromised as

far as possible.

For any changes proposed that may involve alterations in the width of the anterior teeth,

the law of golden proportion should be closed followed. This enables the esthetic dentist to plan

any space manipulations for the restorations in terms of illusions, actual tooth positional changes

such as rotations overlaps, spacing etc.

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. Profile analysis

While examining the patients profile, the normal profile is referred to as straight

orthognathic. Any deviation from this should be recorded and considered in treatment planning.

Examination of the profile could be in the antero-posterior plane or in the vertical plane.

Computer Analysis

Radiographs and photographic images have been used as an essential aid in diagnosis,

record keeping, communications and treatment planning. Computer aided technology has

broadened the scope of applicatiosn as well as enhanced the utility of radiographs and

photographs in the dental field. The new intra-oral cameras with digital support and the radio-

visiographs are indispensable tools at the esthetic dental office.

They give enlarged images of the photographic and radiographic outputs on the screen, without

the involvement of any hard copies of photographs or radiographs, with multiple magnifications,

and at various angles, for the dentist as well as the patient to assess and view the intra oral

condition in a different perspective. the proposed treatment modalities may bring about without

actually carrying out the treatment.

In a particular case, esthetic enhancement with a change of arrangement, form, shape or color

can be demonstrated quickly. Thus computer analysis can be used as a quick reference which

can guide the future artistic creations that the dentist may consider, however, the occlusal

parameters cannot be addressed without appropriate devices and hence the actual three

dimensional aspect of the change cannot be applied without error. Promising the patient results

close to what are seen through a computer analysis could lead to dis-satistication and hence the

dentist should consider other diagnostic means before designing definitive treatment plans.
ROLE OF TECHNOLOGY IN CHANGING SMILE

New technology helps us to preview the end results.The following high tech tools can be

incorporated:

1) Extra oral video camera:

It allows to have a detailed record of the patient's face while moving and talking- a

much more helpful tool than a still photograph. It can record the patient in various moods and

gestures and give us the minute details the patient may be unaware of. This can be shown to the

patient with the help of computer imaging . Different smiles and profiles can be applied to the

patient's face and the patient can be given the opportunity to choose the best smile design .

2) Intraoral video camera:

It is an easy to use unit designed with reliability, performance and image quality. Intra

oral examination from every angle with the smallest details can be viewed as close as 2mm. fron

the tooth. With it we can explain certain conditions and treatment options much more accurately

than with sketches, mirrors and X- rays. Introral cameras can be integrated with a computer

imaging system to capture the detailed images of the patient's oral cavity. These images can be

modified according to the proposed treatment options and shown to the patient. At the click of

the mouse a particular tooth can be elongated or widened , the effect of which can be shown to

the patient for his approval.

3) T- Scan and Digital Radiography

By using this scan , buccolingual width of the jaws as well as the location of anatomic

features such as the mandibular canal and the maxillary sinus can be determined which is useful

while placing an implant in the esthetic position.

Now-a-days manufacturers promote digital radiography system and video camera in one

unit i.e. single hand piece which will be concenient for use.
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4) CAD/CAM

With CAD/CAM ( Computer assisted design/ Conputer assisted manufacture) technology

we can design veneers and crowns to enhance smile while the patient waits. The so called

"mock- up" of a planned cosmetic teatment also has been shown to be quite useful. It also allows

clinician to visualise the desired results and solve potential problems before providing treatment

to the patient.

5) Lasers

The dental lasre uses a beam of light in place of scalpel to perform delicate gum surgery

and crown lengthening/ gingivectomy and gingivoplasty.

The advantages of this procedure are-

1) Controlled bleeding which provides dry operating field and hence excellent

visibility.

1) Reduced operating time and reduced post operative swelling, pain and scarring.

6) Computer Imaging

It improves communication between the patient and the dentist by allowing both to visualize

, evaluate and agree on treatment. It allows to " see" various looks before deciding upon

treatment.

7) Abrasive Technology

In this technique , a jet air stream with micro abrasive particles is used to remove the stained

areas. It is painless, faster and does not require the use of anesthesia. It can be used in any

quadrant for any depth of decay without damaging the healthy tooth structure. After the removal

of the stained areas , the tooth structure can be built up with composite.

It is also useful during repairs to existing composite or porcelain restorations because it

roughens these surfaces allowing the reparative materials to bond them more rapidly .
Occlusal considerations

The esthetic dentist has a major challenge in dealing with restorative situations in the

mouth where occlusal considerations are critical. 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 the teeth and supporting

structures. This requires a thorough understanding of the stomatognathic system which

comprises of the temporomandibular joint, the ligaments, related musculature and the dentition

and their coordinated three dimensional movements.

Concept of occlusion

A thorough knowledge of the various concepts of articulation accompanied with

application of the same is mandatory for successful restorative rehabilitation.

The various concepts of occlusion are

• Bilateral balanced occlusion

• Group function or unilateral balanced occlusion

• Mutually protected occlusion

In large or complex rehabilitation’s with fixed prosthesis, a sequential and correct method of

recording the jaw relations should be followed since any error would be magnified in the final

outcome. This would be detrimental to the survival of the surrounding tissues and the restoration.

The hinge axis of the mandible should recorded with a kinematic face bow and transferred to an

adjustable. Arbitrary hinge axis face bow is useful for routine work and gives a fairly accurate

relationship (error of 5mm). Correct centric relationship and protrusive and lateral inter occlusal

records are made in rigid materials and the articulators are adjusted accordingly. Correct incisal
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guidance is computed and adjusted. This logical and systematic approach ensures minimum

error.

Forces on the dentition

On the dentition it is influenced by several factors like position of the teeth in the arch,

masticatory dynamics, relationship with the opposing arch, crown-root ratio, direction, duration,

frequency and character of the forces during functional mandibular movements and

parafunctional habits. The peri-oral musculature and the tongue exert a constant force on the

teeth. These forces are lighter and in a horizontal direction. Swallowing also exerts forces on a

continuous basis throughout the day. The peri-oral musculature and the tongue exert a constant

force on the teeth. These forces are lighter and in a horizontal direction. Swallowing also exerts

forces on a continuous basis throughout the day. The heavier natural forces exerted on the teeth

are during mastication and are primarily directed perpendicular to the occlusal plane in the

posterior region. They are exerted infrequently and for a short duration during the day.

In mutually protected occlusion, where there are no posterior contacts in eccentric movements,

fewer fibers of the temporalis and masseter muscles and stimulated resulting in reduction of the

forces applied on anterior teeth by two thirds.

Research on implant prosthesis and crowns with cast cores on maxillary incisors have

shown permissible angle of up to 25° between the crown and root for maintenance of adequate

periodontal health.

Parafunctional movements: Are identified as a cause for occlusal wear and excessive forces.

Parafunction can be related to local factors like malocclusion or to systematic factors like

cerebral palsy, epilepsy and can also be stress or occupation related. Bruxism, clenching and
parafunctional tongue thrust are the important parafunctions which the dentist should consider in

the treatment planning stage.

Bruxism: Rehabilitation of these cases not only involves elimination of the causative factors but

establishment of correct anterior incisal guidance to eliminate all posterior contacts during

mandibular excursions.

Clenching: Is the force exerted from one occlusal surface to other without movement. These

forces are directed more vertically to the plane of occlusion in the posterior region of the mouth.

Fremitus is often found in the clenching patient. This is vibratory type of a force felt with a

finger kept in contact with the facial aspect of a tooth while the patients taps the teeth together. It

is noticed clinically on many cervically eroded teeth, and if the occlusion is carefully evaluated,

it shows signs of excessive forces. This cervical defect is called cervical abfraction. During the

management of these cervical defects occlusal adjustments need to be considered along with

adhesive restorative methods for a long term success.

Parafunctional tongue thrust: Is an unnatural tongue force which can exert an abnormal

horizontal force on the anterior teeth.

Esthetic treatment planning and sequencing

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, inter disciplinary treatment modalities and is the fundamental

feature of a meticulous treatment execution .

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Although some basic periodontal, pulpal and temporomandibular problems would be addressed

at the initial therapy stage, more definitive periodontal or pulpal treatment may be necessary

during the definitive therapy stage. Certain cases involving endodontic posts or implants etc in

the esthetic zone may pose a challenge to the dentist in term of giving suitable interim

restorations that will not interfere with the healing process.

Mock up

Mock ups are made for diagnostic reasons during the treatment planning phase as well as

for reference purposes during the treatment phase. For the cases requiring major esthetic

correction involving many anterior teeth the dentist can work on the space availability and

allotment for every tooth on the mock up even before proceeding for the tooth preparations.

A cosmetic preview with the help of composite resins is the easiest and fastest procedure to help

the dentist in diagnosis, treatment planning as well as creating references during treatment

execution

Composites can be put on the facial tooth surfaces including spaces or even the gingiva to

determine the change of position of teeth desired at the final restorative phase. The dentist can

show this preview of the patient and get his opinion regarding tooth position, shade, shape etc.

The occlusion usually will restrict the restorative ease in many cases. The lower incisors

should be thoroughly examined and the contacts of the palatal aspect of the upper teeth marked.

The functional movements in the mouth can also be checked at this time to determine any

potential occlusion

Obstructions or difficulties that may arise at the time of treatment. Some adjustment in the

incisal edges of the mandibular incisors might be mandatory before proceeding with esthetic

correction for the maxillary anteriors.

 In cases requiring reduction of tooth structure like in overlapping teeth, a diagnostic wax-

up would be more beneficial as the required reduction of the teeth can be done on the study casts

and suitable colored wax-up can be used to visualize the end result and preparation design.

In cases requiring closure of spaces and where crown lengthening could be required to improve

the width to length ratio of the final restorations, a composite preview could be easily used.

Before crown lengthening procedures the extent of gingivectomy and the exact contour to be

established on the facial aspect contour to be established on the facial aspect is determined by the

location of the gingival zenith after the placement of the final restoration. Hence a composite

preview is used to determine the gingival contour and the gingivectomy is performed according

to this reference. Once crown lengthening is achieved and after sufficient healing period elapses,

composite or ceramic veneer is placed to give the final desired result

COLOR

Dimensions of color

Color cannot be perceived without light, which is a form of electoro-magnetic energy

visible to the human eye. The visible spectrum of light lies in a narrow band of 380nm to

760nm. It has the ability to stimulate the cells in the retina which is interpreted by the brain,

discerning the sense of color.

Clark stated that “Color, like form, has three dimensions”. Hue, which is the name of the radiant

energy, Chroma, which is the saturation of the hue and value, which is the relative lightness or

darkness of the color. Since clinical color matching depends upon the ability of the dentist to

perceive the difference in the tooth shade guide comparison; complete understanding of the color

dimensions in critical.
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The Munsell color order system best serves the needs of the dental profession in its tempt

to visualize and organize color.

Hue: In Munsell’s words, “It is that quality by which will distinguish one color family from

anther”.

Generally there are six hue families. Violet, blue, green, yellow, orange and red. For

example, in the Vita shade guide there are four hues A, B, C and denoting reddish brown, reddish

yellow, grayish and reddish grey respectively.

Chroma: In Munsell’s words, “it is the quality by which we distinguish a strong color from a

weak one. “Human teeth fall into the yellow to yellow red area of the Munsell color order

system. Pale colors have a low chroma whereas intense colors have high chroma

Value: Value or brilliance is the relative blackness or whiteness of color. On a scale of black to

white, white has “high value”, black a “Low value” and Midway between black and white is the

medium grey. Value is the only dimension of color that can exist by itself.

Opacity and Translucency: As light strikes a surface, it is either totally reflected, totally

absorbed or a combination of both. Opaque objects reflect all or most of the light that is incident

on them whereas transparent objects transmit all of the light that is incident on them.

When part of the light incident on an object is transmitted, while the rest is scattered, the

property of the object is known as translucency. It decreases with increasing scattering within

the materials.
Translucency, in effect, is the three dimensional spatial relationship or representation of value.

Highly translucent teeth tend to be lower in value, since they allow light to transmit through the

teeth, while opaque teeth have higher value.

There might be inter tooth as well as intra tooth differences in the translucency. Its extent

can vary according to the age of the patient due to the degenerative and reparative changes in the

enamel and dentin. To mimic natural teeth the effective use of restorative materials should

largely depend upon this translucent effect.

Metamerism

The change in color perception of two objects under different light sources is called

metamerism. For example, a shade guide tooth matches the natural tooth under incandescent

light but not under fluorescent light. This can be attributed to the difference in the radiant energy

of two different wavelengths of light.

The standardization of lighting condition during hade matching diminishes the effect of

metamerism.

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 removal of incident light. Teeth

fluoresce with a stimulus in the range of 340nm to 410nm. This spectrum is in the blue range.

Thus, according to the principles of additive color, the emitted blue light acts with the yellowness

of the tooth to produce a whiter tooth. Fluorescing pigments incorporated in the ceramic

restorations by the ceramist and in the composite restorations by the manufactures may thus be

advantageously used in altering the perception of the final result.

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Gloss: Gloss is an optical property associated with a smooth surface that produces lustrous

surface appearance and thus reduces the effect of color differences. Increase the brilliance

(value0 of the final result.) In dentistry, unlike spectral colors, the restorative materials have

pigment colors incorporated in them.

Perception of color.

The perception of color involves many physiological , physiological and physiological

aspects

The light source.

The light source has the color of the emitted light and is described in color temperature

(Kelvin.). The lighting environment makes significant differences in the perception of color.

The teeth and the shade guide should be sufficiently illuminated. The light reflected from a

glossy surface obscures the viewer’s perception of light. Shadows should be eliminated as they

reduce the available light and hide details.

The dental operator maybe illuminated by combination of natural sunlight and artificial light, the

artificial light may be incandescent (predominantly) blue. Also the ratio between the task light

(which falls directly on the working area) and the ambient light (derived from the surroundings),

known as the contrast ratio, should be higher than 3:1, but lower than 10:1. This can be attained

by regularly measuring the intensity of light, cleaning the diffusers and the light sources any by

replacing them when their effective life is over.

The observer

The stimulus of light travels through cornea, lens, aqueous and vitreous humors and

reaches the cones and rods of the eye. The cones function for day light vision and color

perception whereas rods are sensitive to the quantity of light perceived. These stimuli are then

sent to the brain, where they are computed and interpreted as color. This complexity of color is

further modified by the embryonic development of the brain, aging process, aberrations of color

vision like color blindness, dichromatism, mental fatigue and drug intake.

The object

The quality of the color of an object (the tooth) depends on its ability to absorb, reflect,

transmit or refract the light energy falling on it. The surrounding environment greatly influences

the color. The ceiling and the walls reflect light and should not be pained in bright colors.

Neutral colors like grey or white should be selected.

Contrast effects

The background considerably affects the perception of color. Different contrasts effects

that alter the color vision should be understood.

Simultaneous contrast
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Is visualized when two objects are viewed at the same time. The light or dark contrast

can be correlated to the surrounding environment like skin tone, hair color and brightness of

adjacent soft tissues and teeth. Hence, brighter shades should be chosen for light toned patients

and darker shades for pigment toned patients

Actual contrast

Is influenced by the size and the chroma of the tooth. A brighter tooth looks larger while

a darker tooth of the same dimension look smaller.

Shade selection

Shade selection is a complex procedure due to the variations and differences in the

optical properties of the new generation of cosmetic restoration materials. It can be well

accomplished by understanding the fundamentals of color and adopting a proper methodology of

matching shades. The effective communication with the laboratory and precise fabrication and

meticulous finishing of the restoration will affect the color of the final restoration.

Shade selection sequence

Any color modification procedures like bleaching or microabrasion should precede color

selection after ensuring color stabilization.

 Make the shade selection at the beginning of the procedure as well as over different

appointments (diagnosis, prophylaxis etc.)and cross check these observations.

 View the patients at eye-level. The operator should stand between the light source and the

patient.
 In a contrasting environment, colors look more intense and brighter. Hence it is wise to

ask the patient’s to remove artificial lip color.

Place the tabs as close as possible to the area that is being checked.

 Moisten the tab and eliminate the worst match.

 Evaluate the value (upper to lower). Value is the most important factor in shade

matching. If the value blends, small variation in hue and chroma will not be noticeable. The

value is to be matched with eyes half closed.

 After value, mark the translucency

 Match the chroma (more or less saturated) and finally, hue in that order.

To avoid hue sensitivity, rapid observation is made for 5 seconds (not more than 20 seconds).

Look away; ideally stare at a blue surface, which will readapt the vision to the orange yellow

portion of the spectrum.

 Match prior to tooth preparation, since preparation dehydrates and changes color due to the

debris of preparation.

 Match the tab with the opposing tooth also.

Metamerism complicates color matching, as the tabs look different under different light sources.

The best approach is to use three light sources; cool white fluorescent light, incandescent

operatory lamp and day light if possible.

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

increase chroma

 Shade tabs of different batches don’t always match; hence it is wise to send the actual

selected shade tab to the technician.

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 Make a decision regarding relative translucency, area of hypo calcification, increase

saturation, crack lines surface texture and other characterization. Make a drawing of the facial

surface and record all patient information graphically.

DENTAL BLEACHING

Bleaching is one of the most commonly sought elective dental procedures to brighten a smile. It

is a simple, fast and effective treatment to change darker tooth shades into lighter ones.

Chemistry of bleaching

Bleaching process is based on the oxidation of bleaching agent. Oxidation is the

chemical process by which organic materials are converted into carbon dioxide and water. The

oxidation reduction reaction that takes place in the bleaching process is called the redox reaction.

Bleaching slowly transforms the organic substance in the stained tooth into chemical

intermediates that are lighter in color than the original tooth shade. In a redox reaction the

perioxide (oxidizing agent) has free radicals with unpaired electrons, which it gives up,

becoming reduced. The stained tooth structures accept these electrons and becomes and

oxidized, thereby reducing the organic colorants. The free radicals produced by the peroxides

are perhydroxyl and nascent oxygen. Of these, the perhydroxyl is a more potent free radical

which is responsible for a better bleaching action.

In order to promote the formation of perhydroxyl radicals, the peroxide is buffered to a pH range

of 9.5 to 10.8. The buffering provides a greater amount of perhydroxl radicals, which results in a

better bleaching effect.

The most common bleaching materials used are hydrogen and carbamide peroxide.

Carbamide peroxide first breaks down into hydrogen peroxide which then further liberates the
above mentioned free radicals. Unlike the hydrogen peroxide, the carbamide peroxide bleaching

agent must remain in contact with the teeth for a longer period of time to obtain complete

efficiency of the reaction. Carbamide peroixde is less irritating to the gingival tissues thus better

tolerated by the patients when used as a home bleaching agent.

Mechanism of bleaching

In the presence of moisture as well as surface debris on the tooth, the ionization by

hydrogen peroxide occurs by decomposition into water and nascent oxygen which is a weak

radical making the peroxide which is a weak radical making the peroxide inefficient as a

bleaching agent. Hence, it is important to have teeth dry and free of surface.

Increase in the temperature, higher peroxide concentration and the duration of exposure

of the tooth structure to the peroxide within the oxidation process leading to a greater degree of

color change.

Saturation Point

Prolonged used of a bleaching agent causes the whitening action to slowdown beyond a

point during the treatment. This is the saturation point. The bleaching if allowed to continue,

begins to break the inorganic structure from the enamel becomes rapid. Bleaching should thus

be stopped at or before the saturation point.

If bleaching is done beyond the saturation point, it clinically manifests an increase in

porosity on the tooth surface. A fluoride application is recommended and no bleaching agents

should be applied allowing the enamel to remineralise.

Procedure for bleaching

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Use of concentrated heroine or carbamide peroxide solution available in standard 35%

concentrations. In a technique described as ‘assisted office technique’, 35% carbamide peroxide

is tray loaded for 45 minutes, after following required protocols. Some bleaching materials are

available in a combination of a hydrogen peroxide and carbamide peroxide in 20% and 16%

concentrations respectively.

Preparation of trays

The bleaching procedure is recommended for the number of teeth seen in the patients

active smile. 1 millimeter reservoir for the bleaching gel. On the modified cast soft and clear

vacuuform matrix of 0.035”thickness is made. The matrix, carefully trimmed to cover only the

clinical crowns. Contact of the bleaching gel with marginal gingiva may result in tissue irritation

hence vacuuform trays should have a marginal seal to eliminate contact of the caustic bleaching

gel with the gingiva.

Isolation of teeth

Proper isolation of area with cotton rolls or rubber dam is mandatory. The gingival

surface is wiped and dried sufficiently.

Etching of tooth surface

Each tooth is etched on labial surface for 10 to 20 seconds using 32% - 37%

orthophosphoric acid. This step removes any superficial surface stains and enhances the

penetration of the bleaching solution into the tooth surface producing a greater stain reduction.
Excessive etching causes the demineralization of the enamel matrix, leading to surface

irregularities and causing sensitivity.

Application of bleaching material

The bleaching materials is slowly loaded in to the vacuufrom trays so that it spreads all

over the labial surface of the teeth to be bleached. The trays are kept in place for an average

duration of 30 minutes depending on the type of material used and the manufactures

recommendations.

Micro-finishing and polishing

Following bleaching, the teeth are micro-finished using fine abrasive disks. Final

polishing is done with aluminum oxide or fine grit diamond.

Office bleaching of non vital teeth

The two most commonly used agents for bleaching of non-vital teeth are hydrogen

peroxide and sodium perborate.

Home bleaching

Bleaching may be carried out at home by the patient. The home bleach technique

involves the application of bleaching agent through the use of vacuuform trays. The frequently

used bleaching agent is 10% - 15% carbamide peroxide.

Bleaching in relation to bonded restorations

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It was determined in clinical studies that the bond strength of composite to enamel is

reduced when the tooth is bleached. The primary cause for the reduced bond strength is the

presence of the residual peroxide or oxygen, which interferes with the polymerization of resin

bonding systems and restorative materials. Any bonded restorations in the bleached teeth need to

be done after a period of two weeks.

Enamel microabrasion

Hydrochloric acid *18%) pumice abrasion can remove white enamel opacifiers, multicolored

defects and many brown, orange, yellow enamel spots and streaks, regardless of etiology. These

stains can be eliminated with insignificant enamel loss if the stain is limited to a thin layer of

tooth surface (approx. 0.5mm). This procedure can be used independently or prior to bleaching

to give optimal results.

Management of Fluorosis stained teeth

A solution of anaesthetic ether, hydrochloric acid and hydrogen peroxide may also be

used for bleaching teeth with fluorosis stains. The anaesthetic ether removes surfaces debris, the

hydrochloric acid etches enamel and hydrogen peroxide bleaches it.

ESTHETICS WITH COMPOSITES

Considerations in preparation design for anterior teeth.

The preparation design for anterior composite restorations should encompass elimination

of decay, function and longevity, and esthetic predictability.

Function and longevity

 A pre-operative analysis of the occlusion is crucial to determine the palatal extensions

and the acceptable length in upper anterior restorations.

Checking the lateral and protrusive excursions will give an idea as to how far palatally the final

restoration can be placed. Researchers have found that a minimum of 1.5mm – 2mm of the

composite thickness is essential to give sufficient strength to the material. A conscious effort has

to be made to leave at least 2 mm of composite thickness at the margins for good marginal

adaptation and retention in larger restorations.

Esthetic predictability

After elimination of the decay and determining the extent of preparation required for

function and longevity, the preparations are evaluated and if required redefined. The preparation

design is extended to allow a smooth transition of shade from the composite restoration to the

rest of the tooth. This enables the restorations to achieve esthetic excellence.

To create proper tooth from, shape, shade and texture, and to optimize function, all cavity

preparations designs should have extension for function and esthetics (EFE).

The EFE ensures that the margin of the restoration overlays the defects. The esthetic advantages

are :

 Successful masking of the defect

 Better marginal adaptation

 Natural transition of shade between composite and tooth

 Ease of finishing and texturing

EFE and placement of composite for malaligned teeth

The preparation in mal aligned teeth is a typical and depends upon the degree of rotation

and angulation exhibited by the teeth and hence a uniform layer of composite cannot be placed to
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treat such teeth. The effective use of opaque composites in areas having no tooth or thin palatal

structure, improves the blending of the restoration. Creating surface characteristics and

effectively placing the transitional angles on the facial surface can help to over come deficiency

in tooth reduction.

EFE and placement of composite for closing spaces

Diastema may be manifested to due to microdontia, discrepancy between tooth size and

the available ridge and also due to variation in the tooth morphology. Although some natural

spaces may be esthetically and phonetically acceptable, others are not and need corrective

restorative procedures. However, in cases where the size of the teeth is normal and a diastema

still exists, restorative creations using principles of illusion is recommended.

When a diastema is small up to 2mm, no tooth preparations is required. The minimal thickness

of composite can be adequately shaped especially at the cervical region to allow good

maintenance. However, in cases of a moderate diastema between 2-4mm the EFE should be

given on the proximal curvature of the labial surface of the tooth. The extension preparation is

close to the gingival margin and follows the contour of the inter dental papilla to end on the

palato-proximal line angle. The preparation is in the form of a depression, which provides a

definite stop and is done with a chamfer bur.

The preparation design ensures adaptation of sufficient bulk of the composite at the gingival

margin creating contours favorable for gingival health. The labial extension allows smooth

blending at the composite tooth interface while the palatal extension provides stability and

retention. In cases with diastema larger than 4mm a similar preparation coupled with

recontouring of the other proximal surface of the tooth to maintain tooth proportions and form

may be required.
Diastemata are filed in one tooth at a time. A celluloid matrix is effectively used to get the

desired contour

EFE and placement of composites in cervical defects

Cervical defects are caused due to caries, abrasion, erosion or abfraction and a

combination thereof. Although management of these defects involves similar procedures, their

proximity to the gingiva makes it difficult to restore. Before any preparation, a gingival cord is

placed in the sulcus to allow a proper access to the defect and to keep away sulcular fluid or

blood from the cavity margins. Since bond strengths with the cementum are weak, no additional

bevel is recommended at the cervical region in cases where the base is in the cementum.

A round bur is used to roughen the surface of the cavity and a long bevel is placed on the

occlusal edge of the cavity. After etching, the cord ischanged and bonding adhesive is applied

followed by flowable composite which is used as an intermediate layer. The gingival cord is

removed after completion of the filling to facilitate finishing and polishing. The occlusion is

adjusted, especially eccentric contracts, to take care of primary or secondary abfractions. Fine

diamonds or carbides are used to finish the margins.

Tissue management

Success of composite restorations depends not only on preparation design, bonding

procedures, and quality of restorative material and skill of the dentist but it also largely

dependent on the thoroughness of the isolation. The greatest challenge involved in creating

predictable composite restorations near the gingival margins is to achieve hemostasis and control
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of sulcular fluid. Therefore, tissue management becomes an integral element of these

procedures.

In case of contamination of composite by blood, blood pigments containing iron or ferric

sulphate migrate between the composite and tooth surface or between different layers of

composite. These pigments turn dark and are visible as a black-brown discoloration in the

restorations. Salivary contamination as well as crevicular fluid ingress in the preparation can

cause bonding failure

s at these areas leading to the failure of the restoration.

Retraction cords displace the gingiva and keep blood and suclurlar fluid away allowing proper

access with contamination during placement and finishing of composites. In cases where the

cavity design is close to the gingival margin, double retraction technique can be effectively used.

Astringent impregnated cords should be used with caution as nay residual astringent can

potentially contaminate the tooth s to be bonded causing a bonding failure.

Shade matching

Shade selection is done following standard protocol with references to the incisal third,

middle third and the cervical third of the tooth. The uniqueness of composites permits pilot

shade test to reconfirm shade attributes before final restorations. The pilot shade test is carried

out using a selected shade in a bulk of 1.5mm- 2mmon the involved tooth and a contra lateral or

guide tooth. The composite is then cured and finished and the accuracy of the shade match is

confirmed. Any changes in the value, transluency and chroma are recorded and the shade is

changed if required.

Three procedural steps for finishing and polishing

 Gross reduction, contouring, defining the margins. Fine grit diamond abrasive or tungsten

carbide finishing bur can be used for the these purposes (100µm size abrasives)

 Intermediate finishing is used to reduce scratches left by gross reduction and to blend all

surfaces with each another keeping the orientation of various facial planes intact (less than

100µm but morethan 15-20 µm particle size).

 Final abrasive polishing imparts enamel like effect on the restorations. Loose abrasive

devices, disks, pastes with particle size less than 20µm is used.

ESTHETICS WITH CERAMICS

Ceramics laminate veneers

In 1930 Charles Pincus used a unique procedure to improve the smiles of certain Holly

wood actors. This technique was non-invasive and gave good esthetic results with resin and air

fired ceramics. But the veneer coping made then lacked permanent retention and later this

technique was discontinued.

Considerations in tooth preparations for ceramic laminates

Tooth preparation design will depend upon the existing color of the teeth, whether change

in alignment or an increase in height of the final restoration is sought. When a mild to

moderate discoloration has to be masked the preparation can be minimal from 0.3mm cervicaly

to 0.5mm at the incisal edge. Whenever a severe discoloration has to be masked the preparation

has to be deeper to allow more die spacer to be applied on the model. His excessive space allows

use of resin curing cement to mask the severe discoloration. Adding more opaque ceramic in the

veneer will mask undesirable tooth color but will limit the display of vitality.
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A more translucent ceramic will allow more light transmission and reflection internally making

the restoration more vital. If change in alignment is indicated then more preparation will be

required in certain areas. When length of the veneer has to be increased a palatal extension is

recommended.

Preparation of maxillary teeth for ceramic laminates

 Mock preparation on the pre-operative casts and diagnostic wax up gives valuable

information about he amount of tooth preparation and helps to visualize the end result.

 Local anesthesia may be required when the preparations reaches the dentin and to

facilitate easy gingival retraction procedures.

 Self-limiting three-tiered depth cutting burs of known dimensions (0.3mm and 0.5mm)

facilitate repaid, adequate and conservative tooth reduction. The depth roves are made by moving

them on the facial surface from the mesial to the distal and by changing the angle of the bur to

facilitate their orientation in two planes (Fig. 8-1a). Then the facial reduction is achieved

following the labial contour of the tooth till the depth grooves. Besides, the contra-lateral tooth

can be used as a reference to check adequate tooth preparation. Selective labial tooth preparation

is required to create a favorable arch form.

 A modified chamfer margin is preferred to allow distinguishable finish line in the

impression, definite seat and adequate bulk for laminates. The margin is usually supra-gingival

or equip-gingival. The margin is taken intra-crevicularly in certain cases to mask the underlying

discolored tooth and cover cervical lesions.

 The proximal finish line is placed into the embrasure area to ensure that the margin

between the laminate and the unprepared tooth structure is well hidden. Deficient preparation

reveals unaesthetic margins proximally.

 Incisal preparation depends on whether an increase in tooth height is required or not. In

case where the increase in not sought, the incisal preparation ends midway between the labio-

lingual width of the incisal edge. In case when the length of incisor is to be increased, the incisal

o
table is flattened with a bevel of 45 palatally. The palatal preparation is a wrap-around design

with the margin placed inferior or superior but never at the contact of the mandibular incisor in

centric occlusion

 Similarly, window preparations are advocated for canines and premolars when increase in

height in not required.

 When the length has to be increased, the anterior and lateral guidance has to be considered

and appropriate tooth preparations has to be carried out to allow for adequate thickness of the

laminate at the incisal or occlusal area.

Try in

Chair side try-in is done to check individuals veneer fit, collective fit of veneers and the

shade of the composite luting cement that should be used to get the desired final result.

Individual veneer is tried for marginal fit, adaptation and retention. Any premature

contacts are relieved at this stage. The veneers should fit in passively with good contacts and not

actively as it may lead to displacement of some veneers.

After Cementation

The patient is viewed periodically for the gingival response and maintenance regimen.

Usually a 3month check up followed by a 6 monthly check up is recommended.

Metal ceramic and all-ceramic restorations

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Metal ceramic and all ceramic restorations have excellent esthetic potential.The metal

ceramic restorations owe their popularity to the simplicity of bridge construction, durability,

strength, marginal adaptation and versatility of use.

Can be used successfully for various complex clinical situations like long span bridges, full

mouth rehabilitation as also a number of semi-fixed type of appliances.

All ceramic restorations are characterized with a dentin like core which makes it possible

to mimic the translucency of natural teeth. They are bio-compatible with the gingival tissues

and exhibit excellent marginal fit. All ceramic restorations are indicated for crowns, veneers,

inlays, onlays and three unit bridges with the premolar as the distal most abutment.

Although all anterior teeth were esthetics is a prime concern can be indicated for all ceramic

restorations, caution has to be taken when a para-function, exists, when tooth structure is

insufficient to support the ceramic, in short clinical crowns and when the lingual preparations is

thinner than 0.8mm. In such cases a metal ceramic restorations is functionally stable and

indicated.

Imperatives of tooth preparations

 Length and taper of the preparation for retention and resistance.

 Enough reduction to allow thickness of the ceramic for excellent esthetics.

Occlusal clearance for occlusal function and anterior guidance.

Tooth preparations for metal ceramic crowns.

The incisal edge reduction of 1.5mm – 1.8mm and the occlusal reduction of 1.5mm –

1.7mm with functional bevel is recommended . Reduction is achieved by using a wheel diamond

on the incisal edge or a round diamond of known diameter in the occlusal grooves. The incisal

edge reduction is followed by the labial reduction. When reducing the labial surface of the tooth,
the exact contour must be emulated. This helps to prevent excess removal of tooth structure

which may lead to deficient lingual wall preparation especially at the incisal aspect. The labial

reduction is achieved in two planes with a round-ended tapered bur, the first orientation involves

the incisal two thirds of the tooth.

The palatal reduction is carried out allowing sufficient space for the crown and to re-

establish normal occlusal and protrusive relationships. A pear shaped or rugby diamond is used

to reduce the lingual concavity while the rest of the cingulum surface is reduced with a round

ended tapered diamond bur.

The proximal reduction involves smooth movements from the labial surface to the palatal

allowing is finished margin on the proximal surface. Long tapered fissures can be initially used

followed by round ended fissure burs to achieve desired reduction. Preparations must include

1mmm peripheral shoulder or chamfer with bevel for ceramometal crowns. The objectives are to

achieve a convergence angle of the axial walls in the range of 6 to 10 degrees.

A shoulder with a 90 degrees cavo-surface angle or a stopping shoulder of 120 degrees is

recommended for a adequate support of porcelain. When the metal margin is shortened for

esthetic reasons, shoulder porcelain requires 1.2mm of tooth reduction at the margin. The

shoulder with a long bevel is advocated for improved marginal fit but it cannot be accommodated

in shallow gingival sulcus. Hence short bevel of 0.5mm with a cavo-surface angle of 135 degrees

is preferred.

Chamfer (0.5mm) is the finish line of choice for metal backing. For porcelain fused to

metal backing, a metal collar on a modified chamfer is preferred. The palatal chamfer is blended

smoothly with the labial shoulder lingual to the contact area for good esthetic results. All sharp

line angles within the preparation should be rounded to reduced stress concentration.
 Smile design
Tooth Preparation for all ceramic crowns.

Although the preparation sequence for all ceramic restorations is similar to the metal

ceramic one, the main concern for the dentist in the preparation for the all ceramic crowns should

be to minimize the stresses that could be incorporated on the ceramic in function.

The length of the preparations is important as load applied from a lingual direction on

short preparations can lead to severe compression of the labial shoulder leading to a fracture.

The incisal edge is reduced to get flat area however a reduction in excess of 3mm is avoided. In

some cases a reduction of up to one third of the crown height may be required to get rid of the

thin incisal edge. The facial reduction is achieved in two planes at a depth of 1mm to 1.5mm.

The lingual aspect should be shaped to remove any uneven surface or sharp line angles and

should incorporeated or sharp line angles and should incorporate a definite lingual concavity

with a high lingual axial wall whenever the cingulum prominence and occlusion is favorable.

Lingual depth should be 1mm – 1.5mm and should not be less than 0.8 mm. The proximal

preparation is completed with a taper of 6o-8o and will help in one path insertion. Excessive

taper will cause inadvertent forces on the ceramic and leads to reduction in flexural strength.

The facial reduction, lingual reduction and the proximal reduction should end into a well defined

shoulder.The shoulder should not create any undercuts for the restorations and hence any angle

in excess of 90o should be avoided. The shoulder should not necessarily be uniform labially,

proximally and lingually, as excessive reduction may be required to do so, compromising on the

resistance and retention form of the preparation. The shoulder is usually 0.8mm – 1.0mm wide

in the labial and lingual and 0.5mm – 0.6mm in the proximal aspect where the ceramic flares to

give sufficient strength. The smooth finish line should not be steep inter proximally but have a

smother gradient to avoid potential stress area during function.

 As compared to the preparation for metal ceramic restorations, the finish line for all ceramic

restorations should be a shoulder which is at right angles to the direction of stress thus increasing

the fracture resistance. In the final preparation all sharp line angles and undercuts are avoided

providing maximum strength and resistance. Adequate length of the preparation is required in

order to counter the tipping forces and increase the surface area for additional retention.

The depth of the facial and lingual shoulder should be 1.0mm (with a minimum of 0.8

mm) and interproximally the shoulder can be 0.5mm as the restoration flares interproximally. A

o o
taper of 5 - 10 is advisable for conservity and increased support to the restoration. Increased

taper leads to stress concentration in areas where the support is lacking.

Try-in

All metal castings are evaluated for margin integrity, internal fit, stability and adequate

space for ceramic material. Intra occlusal relationship record is needed in extensive rehabilitation

cases. Bisque trials for ceramic restorations are assessed for location, site and tightness of

proximal contacts, marginal adaptation and favorable centric and eccentric occlusal contact

without interferences. Besides the shape, contours and color; adequate surface characterization is

checked and incorporated.

The trial for all ceramic restorations are assessed for a passive fit, margins, proximal

contacts, stability, shade, form, characterization and occlusion.

IMPLANT – ESTHETICS

Pre-implant esthetic consideration

In cases of anterior implants in the esthetic zone, certain specific esthetics criteria have to

be considered. When esthetics is the prime reason for seeking implant prosthetic treatment, the

patient’s upper lip line will be of extreme importance for the planning of the definitive
 Smile design
superstructure. In patients with a high lip line or requiring upper lip support from the prosthesis

a removable over denture will more likely fulfill the demands of function and esthetics than an

implant borne bridge construction.

The single tooth anterior implant situations are of great concern as the esthetic requirements and

expectations have to be properly balanced keeping in mind anticipated post-surgical results. The

dentist should analyze anterior single tooth implant situations considering the adjacent teeth,

contra-lateral tooth, probable emergence profile and presence or absence of inter dental papilla

when ever the active smile exposes enough of gingival tissues.

There are many limitations and contra indications specific to the maxillary single tooth implant

apart from the routine contra indications associated with implant therapy. The common causes of

a missing maxillary tooth are traumatic loss, root fracture, agenesis and periodontal disease. All

these leave some deficiency in the facial bone over the root of the missing tooth. Majority of the

cases of maxillary single tooth implant in patients with high upper lip line require bone grafting

for ideal esthetics while in some cases bone grafting would be necessary to provide adequate

healthy peri-implant soft tissue to maintain optimal hygiene in the cervical region.

Apart from the inadvertent deficiencies in the facial bone associated with various clinical

situations, the soft tissue form also plays a major role in the esthetic outcome of single tooth

implants.

In 1989, Misch reported 5 prosthetic options available in implant dentistry. The first

three options are fixed prosthesis (FP). The next two options are removable prostheses (RP).

Prosthodontic classification

FP – 1 Fixed Prostheses, replaces only the crown, looks like a natural tooth.
FP – 2 Fixed Prostheses, replaces the crown and a portion of the root; crown contour appears

normal in the occlusal half but is elongated or hyper contoured in the gingival half.

FP – 3Fixed Prostheses; replaces missing crowns and gingival color and portion of the

edentulous site; prostheses. Most often uses denture teeth and acrylic gingiva, but may be

porcelain to metal.

RP – 4 Removable prostheses; over denture supported completely by implant.

RP – 5 Removable Prostheses; over denture supported by both soft tissue and implant.

Fixed Prostheses

FP-1 is a fixed restoration and appears to the patient to replace only the anatomic crowns of the

missing natural teeth. There usually has been minimal loss of hard and soft tissues. The final

restorations appears very similar in size and contour to most traditional fixed prostheses used to

restore or replace natural crowns of teeth.

FP –1 prosthesis is most often desired in the maxillary anterior region. However the width and /

or the height of the crestal bone is frequently lacking, augmentation is often required before

implant placement to achieve a natural looking crown in the cervical region because there are no

inter dental papillae in edentulous ridges, gingivoplasty is required after the abutment is

positioned to improve the interproximal gingival contours. Ignoring this step causes open “back”

triangular spaces (where papillae should usually be present) when the patient smiles. The bone
 Smile design
loss and lack of inter dental soft tissue complicates the final esthetic results, especially in the

cervical regions of the crowns.

FP-2 fixed prosthesis restores the anatomic crown and a portion of the root of the natural tooth.

The volume and topography of the available bone dictate a deficient vertical implant placement

compared with the FP-1 prosthesis, which is more apical compared with the cemento-enamel

function of a natural root. As a result the incisal edge is in the correct position, but the gingival

third of the crown is over extended, usually apical and lingual to the position of the original

tooth. If the high lip line during smiling or low lip line during speech are favorable and do not

display the cervical regions, the longer teeth are usually of no consequence. FP-2 prosthesis that

is not hidden by lip position during smiling or speech can be solved by using a removable soft

tissue replacement device.

The FP-3 is a fixed restoration that appears to replace the natural teeth crowns and a portion of

the soft tissue. As with the FP-2 prosthesis, the original available bone height loss decreased by

natural resorption or osteoplasty at the time of implant placement. To place the incisal edge of

the teeth in proper position for esthetics, function, lip support and speech, the excessive vertical

dimension to be restored required teeth that are unnatural in length. The patient having high

maxillary lip line during smiling and low mandibular lip during speech will display the longer

teeth which look unnatural. In the AP 3 the restored gingival colour and contour give the teeth a

more natural appearance in size and shape and mimic the inter dental papilla region. The

addition of gingival tone acrylic or porcelain for a more natural appearance is often indicated.
RP-4

It is a removable prosthesis completely supported by implants and or teeth. It may draw

the same appearance as an FP-1, FP-2, FP-3 restorations.

RP –5

It is a removable prosthesis combining implant and soft tissue support. The prosthesis is very

similar to traditional over denture.

Factors for favorable implant placement

The physiologic limits with in which the implant can be placed are governed by the

following

 The space between implant and periodontal ligament of the adjacent tooth should be

1mm.

 The average width of periodontal ligament is 0.25mm.

These natural periodontal components will require a space of 1.25mm on either side of the

implant. Thus, mesio-distally the implant diameter is added to this minimum space required.

The facio-lingual requirement. For a 3.5mm implant placed in the anterior region a minimum of

6mm of space mesio-distally has to exits to accommodate all related components. Ideally, the

ridge should be 5-6mm wide labio lingually, to allow at least 1 mm of the cortical bone labially

and lingually. However, to impart esthetics in the inter dental papilla region, the distance

between an implant and natural teeth is kept 2mm.

The implant should be 3mm apical to the gingival margins of the adjacent teeth.

Labio-lingual orientation of the implants helps to achieve desired emergences profile.

Placing the implant slightly palatally helps the dentist to build up a proper emergence profile to

the crown.
 Smile design
To obtain satisfactory peri-implant gingival morphology, tissue volume should be 20-25%

more than the estimated need to allow adaptation of gingiva to the prosthetic reconstruction.

Wider diameter implant will ease the transition of the implant head to the artificial crown as it

emerges from its soft tissue housing. The wider diameter implants will not be required to be

placed far apical to the cemento-enamel junction of the adjacent tooth. Immediate implants help

to preserve the hard and soft tissues, and maintain the emergence profile as in natural teeth.

PERIO – ESTHETICS

Esthetic periodontal considerations:

Shape and position of the gingiva:

In an ideal esthetic relationship, the position of the gingival margin is dictated by the

vertical limits of the active smile, the gingival margins of the maxillary central incisors and

canines positioned at the vermilion border of the upper lip. The gingival margin of the lateral

incisors is usually located 1 to 2 mm more incisally or at the same height of the central incisors

and canines.

The gingival zenith is distal to the long axis of the tooth for both the maxillary central

incisor and canine while it is situated on the long axis of the tooth for the maxillary lateral

incisors.

The gingival height of contour of the premolars and molars lies in a more occlusal position as it

moves posteriorly.

The horizontal limits as well as the vertical limits of the smile should be evaluated. Most

patients show the maxillary teeth with or without the gingiva upto the first molar in an active

smile. To provide for proper depth and harmony of the smile, the gingival display should be

consistent and proportional from tooth to tooth, from the left first molar to the right first molar.

Embrasures
 In healthy periodontium the inter dental papilla blends into embrasure spaces completely

from buccal to lingual which is an important esthetic factor assuring harmony in the dental

composition. However, in cases of recession or post-periodontal therapy the embrasures may

open up revealing a black triangle.

Biologic width

It has been demonstrated fro autopsy recordings that the mean sulcus depth is 0.69mm,

mean length of the junctional epithelium is 0.97mm and connective attachment is 1.07mm; the

combined width of the latter two is 2.04 mm and is called the ‘biologic width’. This biologic

width is always present, therefore restorative margins must maintain a distance from the alveolar

crest that respects the biologic width, otherwise gingival recession or pocket formation ensues.

Esthetic periodontal defects and its correction

Periodontal defects posing an esthetic problem.

May include :

 Violations of biologic width

 Gingival asymmetries

 Excessively gingival display

 Localized gingival recessions

 Deficient pontic areas

 Abnormal frena.

 Excessive gingival pigmentation

 Inadequate interproximal papilla

 Smile design
Restorations which are over extended in the cervical region should be carefully removed and

proper cleaning of the teeth is recommended with excavation of deep carious lesions in the

cervical region. Provisional restorations should then be fabricated with proper contouring in the

cervical region. The pockets should be probed and isolated areas of excessive bone loss should

be marked and regenerative procedures instituted.

Surgical technique for establishing proper biologic width involves recontouring the

osseous crest so that a minimum of 3 mm of the flap can be placed coronal to the position of the

recontoured osseous crest. This will take into consideration the average biologic width of 2mm.

In accidental tooth fractures or any other clinical situations where the restorative margins may

violate the biologic width, bone removal in the adjacent teeth might be necessary to get desired

esthetic result.

Gingival asymmetries

Whenever the facial gingiva of the anterior teeth does not follow a symmetrical pattern,

crown length discrepancies are perceived; some teeth appear longer while others appear shorter.

Correcting these discrepancies to an esthetic gingival pattern becomes the main goal of the

esthetic or restorative dentist.

The possible causes of gingival asymmetries are :

 Gingival hyperplasia

 Altered passive eruption

 Tooth or teeth malpositioning

 Over zealous tooth brushing

 Periodontal disease

Esthetic crown lengthening

 When a disparity in the clinical crown length exits between contra lateral teeth resulting

in a left/right side height discrepancy, esthetic surgical correction can be provided to enhance the

cosmetic result before restorative measures.

functional crown lengthening

In such cases ‘esthetic crown lengthening’ may be carried out by performing gingivectomy and

or osseous resection only on the facial aspect, for better esthetics. Root exposure is often a

common complications and intentional root canal or post surgical treatment with veneers or

crowns may be required.

Excessive gingival display (gummy smile)

A gingival display of more than 3mm in active or moderate smile may be termed

“gummy”. Excessive gingival display or gummy smile can be caused by any of three factors.

The causes include:

 Maxillary over growth

 Tooth malposition

 Delayed apical migration of the gingival margin or altered passive eruption.

Crown lengthening procedures can correct the latter two defects. Usually a surgical and

orthodontic correction may be needed in these cases.

Deficiencies in edentulous ridges

 Smile design
Deficiencies in edentulous ridges could be bucco-lingual, apico-coronal or a combination

of tooth. These deficiencies can lead to functional as well as esthetic compromises for

prosthodontic and implant related treatments.

Several surgical techniques have been devised to restore the contour of edentulous ridges

that have been altered by disease or trauma before adaptation of pontics. The most commonly

used classification is as follows:

Class I: Bucco-lingual loss of tissue with normal ridge height in an apico-coronal

direction.

Class II: Apico-coronal loss of tissue with normal ridge width in a bucco-lingual direction.

Class III: Combination of bucco-lingual and apico-coronal loss of tissue resulting in a loss

of normal ridge height and width.

Correction of class I type of defects

Bucco-lingually edentulous ridge defects are the most commonly encountered and most

predictably treated of all alveolar ridge defects. Surgical procedures such as inter positional

grafts of hydroxyapatite or connective tissue are ideal for augmentation for such type of defects.

For connective tissue grafting, the donor site selected is usually the one with the thickest

available connective tissue, such as maxillary tuberosity. Augmenting the edentulous ridge at the

time of surgery slightly more than necessary will compensate for the shrinkage that occurs

during surgical healing.

Correction of class II defects

These are more difficult to treat predictably and are usually corrected with onlay grafts.

Slight defects in any plane of space can be treated. Usually in one stage while moderate to severe
type of defects often require multiple procedures with an interval of 6 to 8 weeks post

operatively.

Correction of class III defects

This is the most difficult type of defect to manage and generally requires multiple

surgical procedures. Palatal donor sites fill in totally within 4-8 weeks and can again serve as

donor sites, if necessary. When multiple procedures are anticipated the bucco-lingual dimension

is generally recaptured first, this sequence provides a broader base (more vasularity) for the on

lay graft.

The provisional restoration design is of crucial importance to maneuver the soft tissues covering

the ridge. For esthetically pleasing restorations various pontic design are used; however much

has been spoken about the ovate pontic. The ovate pontic is highly convex and sits well within

the confines of the alveolar ridge. The ovate pontic contacts the alveolar ridge in a depressed

area, which helps to create good emergence profile for the pontic. However, this pontic is very

difficult for the patient to maintain.

Abnormal frenal treatment

For diastema closure. A resection (frenectomy) or a repositioning (frenotomy) may be

necessary. Whenever there is excessive pressure caused by the frenum, then a frenectomy may

be the best procedure, however when esthetics is the only factor then a frenotomy may be

necessary to give the desired result.

Excessive gingival pigmentation

 Smile design
Skin tone, texture and color differ in races, and different regions the color of the human

gingiva also differs, usually pink with certain areas showing a diffuse pigmentation. Gingival

pigmentation is due to the deposition of melanin pigments in the basal layer of the mucosa. In

mammals it is brown, black or blue black.

The saturation of these pigments causes an unesthetic dark or gingival display. In people

with fair skin and high lip lines. The pigmentation usually occurs in diffuse patches; some times

a continuous area is seen.

The surgery can be performed under local anesthesia with the following techniques.

 Gingivo-abrasion technique

 Split thickness epithelial excision

 Combination technique which involves gingivo-abrasion and split thickness epithelial

excision.

Gingivo-abrasion technique

A medium grit foot ball shaped diamond bur is used at high speeds on the epithelium to

denude it. Care should be taken not to abrade the periosteum.

A periodontal pack is the placed over the denuded epithelium.

Split thickness epithelial excision technique

A split thickness island of epithelium is removed on the attached part of the

mucosa.

A periodontal pack is then placed and left for a week.

Combination technique

In cases where pigments are present very close to the marginal gingiva and where the

gingival pattern as areas of depression and elevations on the facial aspect, a combination

technique is advised. Gingivo-abrasion is used near the marginal gingiva and areas where a split

excision of difficult.

Open inter proximal spaces.:-

The inter dental gingival occupies the gingival embrasure which is the inter proximal

space beneath the area of tooth contact. The shape of the gingival in a given inter dental space

depends on the contact point between the two adjacent teeth and the presence or absence of some

degree of recession. Open inter-proximal space may be caused due to diverging roots, abnormal

clinical crown shape and absence of inter proximal papilla. The first two can be corrected

orthodontically and by the reshaping of the clinical crown respectively. While the last is the most

difficult to manage. Because currently there are no predictable methods to regenerate the inter

proximal papilla.

ORTHO – ESTHETICS
 Smile design
Crown width discrepancy

Size of the teeth is one of the most important elements of anterior dental esthetics. Tooth

size discrepancy is commonly found in patients with peg shaped lateral incisors. Even after

getting the teeth perfectly aligned and the arch forms properly established with orthodontic

treatment, the abnormal shape and smaller size of lateral incisor poses an esthetic problem.

It is therefore imperative to restore the size of the lateral incisors after the completion of

orthodontic treatment for good overall treatment result. To determine the space required to

restore the crown width, during the treatment planning stage, construction of a diagnostic wax up

in an important step to visualize the final result. After removal of the fixed orthodontic

appliances, restorative phase should be immediately started and provisional restorations should

be given before final restorations to avoid relapse.

Maxillary peg-shaped lateral incisors can be restored with ceramic veneers.

Proximal re-contouring

When the widths of the anterior teeth do not follow the golden proportions. Then the

larger teeth should be re-contoured to smaller size and the space thus created is effectively

utilized by the orthodontist to resolve the discrepancy. This procedure is usually done before

starting orthodontic treatment and care should be taken not to alter the morphology of the teeth

and the contact points.

Space gaining for a single tooth restorations

Loss of a tooth in the posterior segment can led to tipping and drifting of adjacent teeth,

poor inter proximal contacts, poor gingival contour, reduced inter radicular bone, and supra

eruption of unopposed teeth such a clinical situations becomes challenging to correct

orthodontically and restore prosthetically. In loss of the maxillary right second premolar led to

medial tipping and mesio-palatal rotation of the first molar. This resulted in reduction in the

pontic space. Large Nance palatal button was cemented for palatal anchorage to move the molar

distally.

Segmental stainless steel wire with compressed nitinol coil spring was placed between the first

molar and the premolar. The maxillary first molar was moved distally creating sufficient space

for the pontic. After provisional restorations the final restorations were placed.

Replacement of missing laterals with implants

Dental agenesis occurs quite frequently, especially of the maxillary lateral incisors, and it

presents true challenge for an esthetic solution.

The osseo-integrated implant is the most conservative and biological method, since the

missing tooth can be replaced without damaging neighboring teeth.

If the use of implants is the part of treatment plan for the missing lateral incisors, it is necessary

to decide the exact placement of implants, evaluate the smile line and gingival contour. When

the lateral incisors are missing, there is usually no adequate space to restore them due to drifting

of the adjacent teeth. In such cases, it is essentially to gain adequate space with orthodontic for

the placement of implant and crown restoration for good esthetic result. The exact amount of

space created should be according to the proposed size of lateral incisors, which should be

proportions to the width of the central incisors.

Before the orthodontic appliances are removed it is important to evaluate radiographically the

position of the roots of adjacent teeth. The roots of the central incisors and canines on either side
 Smile design
in case of bilaterally missing laterals should be parallel to each other with adequate space

between the roots for implant placement.

The minimum space of 6.5mm between adjacent roots is required to place a standard

implant of 3mmm width.

Impaired dento-facial esthetics and function due to absence of canines.

The position of canines in all three planes of space is very important from esthetic and

functional point of view. The ectopic eruption and impaction of maxillary permanent canines is

a frequently encountered clinical problem.

The canines also provide the main gliding inclines for lateral excursions of the

mandible.Thereby providing the patient with a functional occlusion. Therefore, it is not only

important to get healthy favorably positioned impacted teeth into occlusion but also to position

them in such a way that they maintain the integrity of occlusion, provide good function and

optimal esthetics.

Establishing proper anterior guidance

As Angle (1907) stated that, “Each dental arch describes a graceful curve and that the

teeth in these arches are so arranged as to be in greatest harmony with their fellows in the same

arch, as well as those in the opposite arch. The sizes, forms, inter-digitating surfaces, and

positions of teeth in the arches are such as to give one another, singly and collectively, the

greatest possible support in all directions”.

Proper inter-incisal relationship is important to maintain the vertical position of incisors.

Loss of this relationship leads to supra-eruption of incisors and deep bite.

In severe deep bite case, there is often attrition of lower incisal edges and the palatal surfaces of

upper incisors, leading to shorter clinical crowns of the lower incisors and lack of anterior

guidance. In such a clinical situation, if there is any restoration in the maxillary anterior region,

it will have a tendency to de-bond due to lack of sufficient vertical clearance.

Therefore, it is necessary to establish proper anterior guidance with orthodontics so that

the palatal surfaces of upper anterior could provide a harmonious glide path for the lower

anterior teeth during the protrusive excursion of the mandible. These teeth should work against

one another to separate or disclude the posterior segments as soon as the mandible moves out of

centric closure.

Ortho-Perio –Restorative Perspective

An integrated orthodontic, periodontal and restorative treatment is useful in wide variety

of patients for improved occlusal relationships of teeth, proper gingival architecture and esthetic,

biologically sound restorations.

Abnormal gingival architecture

Color, contour and the health of the gingival tissues provide the framework and back –

drop for the esthetic smile.

 Smile design
During the process of eruption the whole periodontal apparatus is carried with the erupting tooth.

When there is asymmetric eruption of the teeth it will also result in discrepancies in heights of

the underlying crestal bone. This, in turn, results into asymmetries in gingival heights (gingival

zenith) from one side of the arch to the other. This type of a clinical situation can be managed

orthodontically by intrusion or extrusion of teeth.

REVIEW OF LITERATURE

Van Zyl I, Geissberger M. (2001) describes a tool dentists can use to show patients potential

tooth sizes, shapes and arrangements before carrying out treatment. Simulated shape design, or

SSD, is a reversible method of demonstrating potential esthetic outcomes that involves creating

trial restoration shapes and placing them over a patient's teeth. SSD is a simple technique that

any dentist can perform. In essence, the technician makes new tooth shapes in wax, the dentist

places these in the patient's mouth and the patient evaluates them. The dentist then makes

modifications in the SSD, which he or she reports to the technician.so that Both the esthetic

(smile design) and functional elements (anterior guidance) of the restoration can be checked with

SSD. SSD could become the standard in determining whether or not to proceed with esthetic

treatment.

E M Narcisi, J A DiPerna (1999) highlights the harmonious integration of modern smile

design, material selection, and interdisciplinary communication that must be addressed in order

to deliver optimal treatment with porcelain laminate veneer and laboratory-fabricated resin inlay

restorations.
Morley J, Eubank J (2000) categorize macro-esthetic criteria based on two reference points: the

facial midline and the amount and position of tooth reveal. The facial midline is a critical

reference position for determining multiple design criteria. The amount and position of tooth

reveal in various views and lip configurations also provide valuable guidelines in determining

esthetic tooth positions and relationships. He concluded that Macro-esthetic components of teeth

and their relationship to each other can be influenced to produce more natural and esthetically

pleasing restorative care.

Dorfman WM.(1995) stated that Even though many patients may simply let you choose a

smile style for them, once you select it, show it to them for their approval. As Jennifer de St.

Georges says, "Inform before you perform. No surprises!" On the other hand, when patients offer

verbal descriptions of how they want their smiles to look, there is a lot of room for subjective

interpretation. By using photographs and models, much of the confusion can be eliminated. After

all, our goal is to make the patient smile.

Messing MG (1995) concluded Successful cosmetic dental treatment is both functional and

aesthetic. It requires evaluation of a patient's expectations, diagnosis of pre-existing problems

and careful planning of treatment to eliminate or control the causes of existing conditions. The

use of mounted diagnostic casts and a diagnostic wax-up allows visualization of the expected

result. Provisional restorations offer a "dress rehearsal" to preview functional and aesthetic

results before completion of the final restorations. The term "smile architecture" is used to

describe the process that guides a patient and dentist from initial complaint through to final case

acceptance.
 Smile design

Singer BA. (1994) introduced to the literature a framework for understanding artistic

principles as they relate to clinical cosmetic dentistry, ie, shaping teeth and creating illusions

In 2001 Tjan HL, Miller JD presented a combination treatment approach to an esthetic defect

resulted from diastema and peg shaped lateral incisors. Minor tooth movement and full coverage

PFM crowns on lateral incisors were completed and then the orthodontic correction of local tooth

malposition through a removal appliance was done. He concluded that these simple procedures

may be valid in optimizing the mechanical and esthetic properties of prosthodontic restoration.

 Mohlt W F, Hovijitra S in1999 stated that closing maxillary and mandibular diastemas is

facilitated by a multidisciplinary approach involving orthodontics and prosthodontics. This case

study demonstrated the management in the discrepancy in maxillary and mandibular anterior

teeth widths. The problem is resolved by limited orthodontic treatment followed by porcelain

laminate veneers. Anterior spacing is one of the major reasons adults seek esthetic treatment.

Multidisciplinary treatment ( periodontics, orthodontics and prosthodontics) is often indicated for

an optimal results.

Haywood V.B. in 1996 stated that bleaching of teeth is the reasonable choice if color of the

teeth is the main concern. However the patient should understand that this procedure is only

considered a temporary measure. Furthermore , whiter teeth are merely an interim measure if

smoking or excessive drinking of liquids that stained are continued.

 Antonio Bello and Ronald H. in 1997 stated that if the patient wishes to improve their smile

because of dark spaces between the teeth, esthetic bonding with composite is the most

conservative approach for several reasons----

a) Sound tooth structure will not be removed.

 b) One appointment is common.

c) Anaesthetics are infrequent

 Carlos Eduardo Francischone et al stated that with the integration of many specialities, it is

possible to achieve the desired esthetics foe anterior prostheses and to develop a harmonious

transition to the surrounding periodontium.

 Roy Sabri in 1999 concluded that missing maxillary lateral incisors with any coexisting

malocclusion must be managed within an overall treament plan.

Factors related to patient , size, shape and position and color of the teeth ; the effect of occlusion;

the overall facial and dental esthetics should be considered when deciding on whether to create

an orthodontic space opening or space closure.

 In 1985 Shapiro described a technique on periodic curettage to stimulate the overgrowth of

interdental papilla destroyed by acute necrotising ulcerative gingivitis.

 Han and Takie H.H. in 1996 described a technique consisting of a pedical graft using a

semilunar incision and the coronal displacement of entire gingival papillary unit.

 Raetzke PB in 1985 described the use of a connective tissue graft placed under a flap for the

purpose of root coverage.

CONCLUSION

Dentistry is an ever changing science.As new research and clinical experience broaden our

knowledge,changes in treatment are required.This paradigm shift in the field of dentistry comes

along just in time to meet the final needs and wants of patient who perceives an attractive smile
 Smile design
no longer as a luxury but rather a necessary part of their life style.Aesthetic dentistry enables the

dentist to change the appearance,size,color,shape,spacing,positioning of the teeth. The allure of

conservative preparations,the potential for excellent esthetic results and gingival

Health has made this branch of dentistry very popular over the world.No wonder it has enjoyed

such a wide spread utilization and at the same time proven itself with such predictable and

excellent results.

Dr. Charles Pincus is rightly recognized as the Father of esthetic dentistry made a prophetic

statement in the year 1937 which is quoted as “A captivating smile showing an even row of

gleaming white natural teeth is a major factor in achieving the dominant characteristic known as

personality.This entails a lack of inferiority complex which causes a hand to be raised to cover

the mouth.

It is this lack of confidence in the dental equipment, which often spells the difference between

success and failure in the life of many people.

The above statement was true in the year 1937 is a reality today and will be so in the years to

come.

REFERENCES:-

1. Solomon EGR: Esthetic consideration of smile; J of IPS 1999: 10(3&4);

2. 41-47

3. Goldstein, RE: Change your Smile, ed 3 Chicago, Quintessence, 1997.

4. Morley, J : The role of cosmetic dentistry in restoring a youthful smile:

5. JADA 1999; 1166-1172.

6. Sohomura T et al : Use of an ultra high speed laser scanner for costructing three

dimensional shape and occlusion: JPD 2000; 84(3): 345- 352

7. Kamal Shigli, Swaraj Bharati: Role of technology in designing a confident smile. J. IPS

Dec. 2001, vol.1, no.4.6)

8. Friedman, MJ and Hodcman, M.N.: P-ASA Block injection: Anew palatal technique to

anaesthetize jmaxillary anterior teeth: J of esthetic dentistry, 1999; 11(2): 63-77.

9. Singer BA. Principles of esthetics. Curr Opin Cosmet Dent 1994;:6-1

10. Messing MG. Smile architecture: beyond smile design. Dent Today 1995

May;14(5):74, 76-9

11. Dorfman WM. How to design smile styles for cosmetic dentistry. Dent Today 1995

Oct;14(10):68-9

12. Morley J, Eubank J. Macroesthetic elements of smiledesign.

Van Zyl I, Geissberger M. Simulated shape design. Helping patients decide their esthetic

ideal.J Am Dent Assoc 2001 Aug;132(8):1105-9

13. E M Narcisi, J A DiPerna Multidisciplinary full-mouth restoration with porcelain

veneers and laboratory-fabricated resin inlays PRACTICAL PERIODONTICS AND AESTHETIC

DENTISTRY , 11(6):721-8; 1999