TABLE OF CONTENTS

1. INTRODUCTION

2. ARTISTIC AND SCIENTIFIC PRINCIPLES

i. COMPOSITION

ii. UNITY

iii. COHESIVE AND SEGREGATIVE FORCES

iv. SYMMETRY

v. PROPORTION & REPEATED RATIO

vi. BALANCE

vii. DOMINANCE

4.FACTORS OF ESTHETIC DENTOFACIAL COMPOSITION & THEIR CLINICAL

SIGNIFICANCE

a. FACIAL COMPONENTS

i. Horizontal references

ii. Vertical references

 iii. Sagittal References

iv. Phonetic references

b. DENTAL COMPONENTS

i. Dental midline

ii. Tooth proportion

iii. Symmetry

iv. Axial inclination

v. Tooth arrangement

vi. Dental morphology

vii. Contact points

c. GINGIVAL COMPONENTS

i. Gingival morphology

ii. Gingival contour

iii. Gingival symmetry

d. PHYSICAL COMPONENTS

i. Principles of illusions

ii. Law of the face

iii. Color

5.ESTHETIC DIAGNOSIS AND TREATMENT PLANNING

 i. PATIENT HISTORY

ii. CLINICAL EXAMINATION

iii. ESTHETIC EVALUATION

iv. SPACE ANALYSIS

v. PROFILE ANALYSIS.

vi. DIAGNOSTIC AIDS

6. PHYSIOLOGICAL/BIOLOGICAL CONSIDERATIONS

i. OCCLUSAL CONSIDERATIONS.

ii. PERIODONTAL CONSIDERATIONS

7.TREATMENT SUMMARY

8. REVIEW OF LITERATURE

9.CONCLUSION

10. BIBLIOGRAPHY
 SMILE DESIGN

Introduction

Esthetic dentistry has become a reality, it is among the most stimulating and active areas
in all the clinical dentistry.Most patients want to look better and feel better about them. This evolution
from nothing to a major part of dentistry has happened in just a few years.In today's world, looking
good is a prime concern. Appearance is closely linked to social acceptance and professional success.
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 individual in the society where he belongs and
the character of the smile influences to the great extent the attractiveness and the personality of the
individual.

Beauty in health is the new mantra. Newer technologies are being harnessed & advanced
research is being undertaken.The focus of dentistry in the present times is not only the prevention and
treatment of disease but on meeting the demands for better esthetics.

Thus, the dentistry has evolved from a curative to a creative science in a very short span. Esthetic
dentistry is emerging as one of the most progressive and challenging branches of this field.
Basically the smile is dependant on the musculature and the presence of the teeth. But every person is
not fortunate enough to have a beautiful smile . The answer to the above problem is the esthetic
dentistry which has developed leaps and bounds with the latest technologies and materials.
Prosthodontist is probably the best person to identify the quality of smile. Further he is also able to
change the quality of smile with the recently available innovative techniques and the state of art
restorative materials and to plan restorations, to harmonize with the smile Deeper understanding of this
subject is required to bring out its complete clinical potential. Esthetic dentistry is characterized
primarily by the smile. The goal in the creation of esthetic dental restorations is to simulate, or improve
upon, the appearance of the natural dentition. However, it is important to note that the smile is just one
element of the face, which serves as the primary means of emotional expression. Therefore, successful
esthetic restorations must integrate harmoniously with the whole of the face, not just with the
surrounding teeth. This requires a full understanding of each patient's unique personality—the
psychology of dental esthetics.
Too often, the pursuit of scientific knowledge results in an overly rigid adherence to standardized
protocols. This reliance on dogma can stifle the creativity and individuality not only of the clinician,
but of the patient, who must be treated as a unique individual. Further this mindset can promote a
scientific culture in which it seems the standardized techniques are exploiting the clinician, and not the
more appropriate opposite . Room must be made in scientific inquiry for creativity, dynamism, and
emotional expression.It is these attributes that push us to find multiple solutions to the problem, in
order to find new and better ways to solve old challenges. This philosophy can find its utmost
expression in esthetics.In dentistry, esthetics is characterized primary by the smile.However the smile
comprises much more than the dental arch.
It all begins with a smile.......

Since the mouth is one of the focal points of the face, it comes as no surprise that a smile plays a major

role in how we perceive ourselves,as well as in the impression we make on the people around us. A

charming smile can open doors and knock down barriers that stand between you and a fuller, richer life.

Leonardo da Vinci's famous Mona Lisa, the enigmatic woman whose identity remains a mystery to this

day,reveals his perspective on beauty. In the Mona Lisa, daVinci finds real "natural" beauty. The

mysterious smile on her face—which could be interpreted as either angellike or quite devilish—was the

secret of her everlasting beauty.The smile is a primary means of emotional expression, and relates to
the entire face. Just as every patient's smile is unique, so too must dental esthetic treatments aim to

account for the specificity and emotional characteristics of each patient.

Analogy can be made to Richard Bach's famous novella, Jonathan Livingston Sea-guff, in which the
title character becomes dissatisfied with a life of flying merely to find—and fight over—food. His
dream is to fly free, explore without boundaries, and gain knowledge through adventure. The quest for
scientific knowledge in esthetic dentistry must follow a similar path, searching for new horizons and
creative solutions to the daily challenge of creating beautiful dental restorations.

It's as old as the pyramids

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

many civilizations noted for their achievements in other areas also demonstrated an interest in cosmetic

and restorative density.

For example, two false teeth encircled with gold wire believed to have been designed as substitutes for
missing molars were discovered years ago in the ancient Egyptian cemetery of EI Gigel. At the height
of Mayan civilization, a system of dental decoration involved filing the teeth into intricate shapes or
decorating them with jadeite inlays. Although times have changed, human nature has not. Fortunately,
modern dentistry not only provides us with better material and technology, but also ensures that today's
procedures are performed with minimum discomfort and maximum safety.

WHAT IS ESTHETICS?

According to Glossary of Prosthodontic terms. January 1999.

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 through its from and or 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 brought about which will have a positive influence on the overall esthetics of
the face. These changes are governed by the principles of esthetic dentistry. “ 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”.

Hence, a good smile design would naturally and effortlessly blend with the rest of the face to provide
an esthetic and functional complex .

The perception of beauty as a corporal expression can vary from one individual to another, one
civilization to another and from one ethnic group to another. Human beauty being a subjective factor
changes the treatment modules of similar problems from one patient to another thus disallowing a
standardization of the treatment plans.

The whole face needs to be considered in totality when trying to work on dental esthetics because the
final picture should be a merger wherein the various features of the face, smile, teeth and gums
complement each other naturally and completely. So a deeper understanding of this subject is required
to bring out its complete clinical potential. Basically an organized and systemic approach is required to
evaluate, diagnose and resolve esthetic problems predictabily. Esthetic dentistry strives to merge
function and beauty with the values and individual needs of every patient. Esthetic dentistry involves a
certain attitude as well as artistic ability and technical competence. Like artists in their paintings,
clinicians should attempt to maintain a balance of proportions in their work. Perfection cannot exist in
isolation: each element of beauty must harmonize with all other related elements to create the whole.
For example, a beautiful face cannot be called so unless all facial features are in harmony.

HARMONY IS THE KEY

The philosophy of beauty and beautification is so wideranging throughout history to the present time
that it has attracted people of all kinds: artists, musicians, and even common man. It makes the
clinician's task of attaining perfect aesthetics even more challenging. Like a musician composing the
different elements that will orchestrate his music, a successful clinician integrates the treatment
elements for a particular patient before executing the treatment plan.

Tooth color is obviously essential in the final result but esthetic treatment planning should
never be devised around shading improvements alone Our ultimate goal as clinician is to achieve a
pleasing composition in the smile – To create an arrangement of the various esthetic elements to proper
proportion or relation according to known principles. The practice of esthetic dentistry must be based
on ethical principles with a holistic approach towards total dental health rather than mere cosmetic
considerations. To think that an artistic predisposition is necessary is a misconception as in any other
discipline knowledge of certain principles is more important than intuition alone. This dissertation will
discuss artistic and scientific principles applied to esthetic dentistry and the process by which our
creative thought and understanding of a patient takes concrete, physical form in the creation of dental
restorations.
 ARTISTIC AND SCIENTIFIC PRINCIPLES APPLIED TO ESTHETIC
DENTISTRY

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

1. COMPOSITION

Vision is possible only if there is contrast.

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.

The relationship between objects made visible by contrasts is called composition, which can be
classified as:

a) Dental composition

b) Dentofacial composition

c) Facial composition

2. UNITY

Gives the different parts of the composition the effects of a whole. Unity can be:

a) Static: as seen in inanimate objects like snowflakes and crystals.

b)Dynamic: active, living and growing as in plants and animals. (Fig.2)

3. COHESIVE AND SEGREGATIVE FORCES

a) Cohesive forces: Elements that tend to unify a composition, represented by elements arranged
according to a principle.

b) Segregative forces: Elements that break the monotony of the composition to provide variety in the
unity.

Harmony depends on the equilibrium created by cohesive and segregative forces.

4. SYMMETRY

Refers to the regularity in the arrangement of forces or objects (Furtwangler, 1964). Symmetry can be:

a) Horizontal/running: occurs when a design contains similar elements from left to right in a regular
sequence
b) Radiating: occurs as a result of the design of objects extending from a central point with the left and
right sides being mirror images.

Horizontal symmetry that is psychologically predictable tends to be monotonous (cohesive forces);

where as radiating symmetry generally represents a segregative force that brings life and dynamism to a

composition.

5. PROPORTION & REPEATED RATIO

a) Proportion: To speak of proportion stems from a notion of relationship, percentage or measure in its
numerical determination and implies the quantification of norms that can be applied to every physical
reality.

Various philosophers have desired to prove the hypothesis that beauty could also be expressed
mathematically.

E.g. GOLDEN PROPORTION (Pythagoras): 1/1.618 = 0.618

BEAUTIFUL PROPORTION (Plato): 1/1.733 = 0.577

(Fig.3&4)

The Pythagorean concept can be found in the composition of the great classical painters and a
meticulous analysis of some masterpieces has evidenced its master full application.

Although by reason of facts proportion is mathematical, it seems more pertinent today to combine the
numerical quantification of beauty with its psychophysical quantification.

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

6. BALANCE

Stabilization resulting from exact equilibrium between opposing forces. In balance, weight of the
elements further from the fulcrum or center grows in importance. If any element is imbalanced on one
side:

 Move the causative element toward the line of forces or midline to relieve visual tension.
 Introduce an opposite element along the same line of forces to promote equilibrium.
(Fig.5)

7. LINES

Many factors that are part of biologic or structural beauty depend on the visualization of lines. Dental
compositions contain a multitude of lines that are more or less expressed as the occlusal plane, midline
or tooth direction.

(Fig.6)

8.DOMINANCE

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

Fig. 1 Beauty is virtual (Plato)

Fig.2 Static Unity Dynamic Unity

 Fig. 3 Fig. 4

Fig. 5

Fig. 6 Equal lines represent important cohesive forces, whereas

cross lines have a stronger connotation of segregative forces.
 FACTORS OF ESTHETIC DENTOFACIAL COMPOSITION AND THEIR CLINICAL
SIGNIFICANCE

An organized and systematic approach is required to evaluate, diagnose and resolve esthetic
problems predictably.

The two main objectives in Dental Esthetics are:

 To create teeth of pleasing inherent proportions and of pleasing proportions to one another.
 To create a pleasing tooth arrangement in harmony with the gingiva, lips and face of the
patient.

The esthetic orientation of the dental composition with the entire facial composition can be
achieved by taking into consideration the references, smile elements, proportions and symmetry.

Four factors of esthetic composition can be simply and effectively be applied to the smile. They serve
to assist the clinician in determining adequate tooth display, tooth size, tooth arrangement and
orientation to the face during esthetic diagnosis and treatment.

 Frame & reference

 Proportion and idealism
 Symmetry
 Perspective & illusion
These factors will be dealt with under various headings relating to the components of the
dentofacial complex, namely:

1. FACIAL COMPONENTS

2. DENTAL COMPONENTS

3. GINGIVAL COMPONENTS
4. PHYSICAL COMPONENTS

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

References can be classified as:

1.1 a Horizontal references (Fig.7)

A horizontal perspective of the face is provided by:

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

1.1 b Vertical references (Fig.8)

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

The facial midline serves to evaluate:

 the location and axis of the dental midline

 mediolateral discrepancies in tooth position

1.1 c Sagittal References

The contours of the upper and lower lip are part of the profile analysis and can be used as a guide
to tooth positions. Various soft tissue analyses are available for the assessment of the profile convexity,
amount of lip protrusion or retrusion, and prominence. For more complex situations and especially
those with skeletal abnormalities, an orthodontic consultation with cephalometric analysis is strongly
recommended.

Upper Lip Support: Upper lip support is controlled to a certain extent by the position of the maxillary
teeth. The gingival 2/3rd rather than the incisal1/3rd of the maxillary central incisors, contributes to the
main support of the lip. (Fig.9)

According to Pound, tooth position more significantly affects thinner and protruded lips than lips that
are thick, retruded or vertical.

According to Maritato & Douglas cephalometric studies, lip support is a better guide of tooth
position than incisal edge position.

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

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

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

1.1 d Phonetic references

The phonetic references that aid in esthetic diagnosis are:

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

 The "F" or "V" sounds are used to determine the lingual tilt of the maxillary central incisor
length.
 The "S" and "Z" sounds determine the vertical dimension of speech. In this position, the incisal
edges of the maxillary and mandibular anterior teeth come in near contact and determine the
anterior speaking space .The amount of posterior speaking space varies with the amount of
mandibular protrusion necessary to bring the anterior teeth in contact for the "8" sound.
Therefore, in patients with a Class I or Class II occlusal relationship, the posterior speaking
space is greater than the anterior speaking space. In terms of dental reconstruction, these
patients can usually accept variance in the vertical dimension of occlusion as long as it remains
within the limits of the vertical dimension of speech. Because the speaking space of patients
with Class III occlusal relationship is approximately the same anteriorly and posteriorly, such
patients cannot tolerate as much variation of the vertical dimension of occlusion because it
would interfere with their speaking space.
1.2 Facial Proportions (Fig.11)

Facial proportions can be different from one individual to another. Proportionate relationships
provide a qualitative value of esthetic appraisal.

Dental, dentofacial and facial compositions contain a variety of relationships that can be evaluated
according to the "golden proportion" in its linear and bilateral values and the variety of geometric
forms. The golden proportion not only symbolizes beauty and comfort at a primitive level, but is also
the key to much of normal physiology. Ideally proportionate faces express a divine proportion as you
compare the width of the nose at the interdacryon (the bony bridge between the eyes) to the width of
the nose at the ala. This progression continues at the mouth width, to the width of the eyes at the lateral
canthus, and finally to the width of the head at the level of the eyebrows.

From the front view, the face is divided: (Fig.12)

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

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

Skeleton, muscles, ligaments and teeth form a cohesive unit. Abnormal facial equilibrium, either
morphologic or esthetic can be ascribed to two major causes:

 Physiological or programmed aging generating changes in muscle and skin tonicity

 Pathologic aging generated by accidental traumas affecting the oral cavity.
Facial aging predominantly affects the lower 1/3rd of the face. Pathologic situations materialized by
the loss of the teeth, migration, tooth wear, faulty restorations or tooth arrangements exhibit profound
morphologic changes that directly or indirectly affect the surrounding structures. Functional
disturbances naturally reflect on facial appearance attesting to the link existing between function and
esthetics.
 A protrusive outward roll of the upper and lower lip showing
a loss of skin and muscle tonicity takes part in the development
of facial sagging. A loss of the vertical dimension of the facial
1/3rd affecting the strength and the extent of the working length
of the infraorbital musculature, predominantly the quadratus

Fig. 10 labii superioris and zygomaticus, induces a muscle collapse.

When this loss is illustrated by anterior tooth wear or lack of dentoalveolar support, an inward roll of
the upper lip margin toward the corners can be observed.

Fig. 7 Fig. 8

Fig. 9
Fig. 11
 Fig. 13. Individual in his 30s
Fig.14 Diagramatic representation of head
posture maintanence and balance of
 Fig. 15 Individual in his early 50s.
Fig. 16 Diagram simulating loss of dental support.
1.4 Tooth Visibility

The amount of tooth exposure when lips and Fig. 18

lower jaw are at rest is, like body posture, a muscle determined position. An interesting study related to
tooth exposure according to gender, racial factors, 8ge and lip length elucidated the extreme variability
of this factor.

 Tooth exposure showed an increase from Blacks to Asians and Whites for maxillary central
incisors and for mandibular central incisors from Asians to Blacks and Whites. (Fig.17)
 People with short upper lips expose the maximum maxillary incisor texture, where as people
with long upper lips expose predominantly lower incisors.

Lip length Exposure of maxillary verticalExposure of mandibular

(mm) incisor central incisor

10-15 392 0.64

16-20 344 077

21-25 218 098

26-30 0.93 1.95

31-36 0.25 2.25

  The study evidenced a significant decrease of maxillary tooth length exposure relative to age,
predominantly between age 30 and 40 years, and a proportionate increase of mandibular incisor
exposure, a situation esthetically, unanimously rejected. (Fig.18)
 The average maxillary incisor display with lips at rest is 1.91 mm in men and 3.4mm in women.

1.5 Components of the Smile

The individual's ability to exhibit a pleasing smile directly depends upon the quality of the
dental and gingival elements that it contains, their conformity to the rules of structural beauty, the
relations existing between teeth and lips during smile, and its harmonious integration in the facial
composition.

Smiles can be classified as :

 Passive: slight parting of lips showing incisal portions of anterior teeth.

 Active: shows more teeth, some gingiva and negative space with lips slightly stretched at the
corners.
 Laugh: maximum exposure of teeth and gums in an enlarged smile window.
1.5a Lip Lines

The amount of tooth exposure during a smile depends on a variety of factors like degree of
contraction of muscles of expression, soft tissue levels, skeletal particularities and design of restorative
elements, tooth shape or tooth wear.

Upper lip line. Helps to evaluate maxillary incisors exposed at rest and during smile and the vertical
position of the gingival margins during a smile.

 It can be classified as low, moderate or high depending upon the amount of tooth or gingival
display at rest or during a moderate smile.
 A smile can be termed "toothy" if more than 6mm of incisal display is seen at rest, or "gummy"
if more than 3mm of gingival tissue are displayed in a moderate smile.

The ideal location of the upper lip height relative to the central incisor is at its gingival margin or 1mm
above it displaying the interdental papilla between the two central incisors during a moderate smile.
Lower lip line: helps to evaluate the buccolingual position of the incisal edge of the maxillary incisors
and the curvature of the incisal plane.

1.5b Incisal Plane

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

1.5c Smile line

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

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

Displeasing patterns include a reverse or concave smile line, or an excessive convexity.

1.5d Upper lip curvature

Is expected to run upward from the central position to the corners of the mouth depending on
the sequence and degree of implication of facial muscles in the development of a smile.
1.5e Negative space

Can be described as the dark space that appears between the jaws at the corner of the mouth or
around the facial aspect of posterior teeth during laughter and mouth opening. It contributes to the
individualization of the dental composition that IS projected by color contrast. This lateral negative
space that results from the difference existing between the widths of the maxillary arch and the smile
has been described to be in golden proportion with the anterior smiling segment.

1.5f Smile symmetry

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

1.5g Occlusal line or Occlusal frontal plane

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

1.5h Smile dominance

Frush & Fisher and Lombard emphasized the need for the maxillary central incisor to be of
sufficient size to dominate the smile, because any composition is based on dominance of a major
element.

Guidelines for pleasant smile dominance:

 Dominance of the central element. Maxillary central incisors exhibit a strong presence by
their size and form.
  Complementarv subsequent elements: Maxillary lateral incisors and canines complement the
central incisor in terms of proper shape and form.
 Pleasing relative proportion: Although numerically, all proportions of the anterior teeth do not
follow the golden rule, the teeth are so placed, they appear in suitable proportion with each
other.
 Order in composition: Similar recurring ratios are observed in the teeth from the central
incisor to the premolar.
 Dynamism of smile: Well coordinated movements of the lips with the other peri-oral
musculature and corresponding harmonious facial expressions, contribute to the pleasant face
during smile.
 Centralized element for unity: The complexion and texture of the face contrast with the lip
color, gingiva and teeth leading to a distinct demarcation between the oral and facial frame.
2.DENTAL COMPONENTS:- 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.

2.1 Dental midline

Both facial and dental midlines are the necessary vectors that enable esthetic appraisal through
the perception of the parameters of symmetry and balance. Logically, the dental midline should
coincide with the facial midline. However, the lack of coincidence between the location and direction
of the two midlines is no esthetic liability unless there is a distinct discrepancy. Verticality of the
midline is more critical than its mediolateral position.

Golub cautions against achieving a perfectly centered midline with the face because it creates
too much uniformity. Conversely, a vertical and centered midline may be used to avert attention from
asymmetrical facial features.
 Research has statistically demonstrated using the lip philtrum as a reference guide, that the
maxillary midline coincided precisely with the facial midline in 70% of the cases, and that esthetics was
not compromised by a slight deviation from the central midline. The same study revealed that maxillary
and mandibular midlines failed to coincide in 75% of the cases.

Anatomical landmarks like the incisive papilla or the labial frenum are used to center the
midline precisely.

2.2 Tooth proportion (Fig.19&20)

Tooth proportion is computed by dividing the width of the clinical crown by its length, which is
ideally 75% to 80% for maxillary central incisors. Below 65%, the central incisor may appear too
narrow, as in Implant crowns or after periodontal surgery. Above 85%, the incisor may appear too short
and square, as in attrition or with altered passive eruption

 Proportion determined by statistical averages: The average WIL ratio of a maxillary central
incisor ranges from 0.74 to 0.89. Wheeler suggested a proportion of 0.8 (8.5 mm 110.5 mm) for
carving technique and this is consistent with the averages of 0.8 (8.5mm I 10.4 mm) found by
Shillingberg et al, 0.8 (9.0 mm /11,2mm) by Bjorndal et al and 0.76 (8.6 / 11.2 mm) by Woelful

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

Hall (1887) proposed the "typal form concept' classifying natural teeth into ovoid, tapering and
square categories.

Berry's biometric ratio advocated that the outline of the inverted maxillary central incisor
closely approximates the out line form of the face. He also postulated with House & Loop that the
mesiodistal width of the tooth was 1/16 of the bizygomatic width,

This geometric theory was challenged when Frush & Fisher (1956) introduced the "Dentogenic
theory" where tooth selection is governed primarily by SAP (Sex, Age, and Personality).

Scientifically, however, correlating tooth form with facial form has been widely refuted.
  Proportion determined by dentist and patient Preference: Woodhead and McArthur
separately demonstrated that molds of maxillary central incisors were narrower mesiodistally
than extracted teeth. Kern studied 509 skulls and found the "biometric ratio" of 1 /16 only on 31
% of skulls. 60% skulls revealed ratios of 1/14 and 1/15. Brisman evaluated preferences of,
patients and dentists and found preference on drawings of the central incisor for 0.75 or 0.80
W/L ratio. On photographs, however, patients still favored the 0.80 ratio while dentists selected
longer and narrower teeth with a ratio of 0.66, possibly conditioned by denture tooth selection.

 Proportion determined by anatomic consideration Isolated studies find some relation

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

 "The Golden proportion” (Fig.21) The application of the golden number to dentistry was first
mentioned by Lombard and developed by Levin. Levin observed that the most harmonious
recurrent tooth-to-tooth ratio was found in the golden proportion. This implies that the maxillary
central incisor should be approximately 60% wider than the lateral incisor, which in turn should
be 60% wider than the mesial aspect of the canine, the distal aspect of the canine being
obscured from the facial aspect. He further demonstrated that the lateral negative space, the area
that appears between the anterior segment of the teeth and the corner of the mouth on smiling, is
in golden proportion to one half the width of this anterior segment. He developed a grid to help
the prosthodontist detect what is esthetically wrong in the anterior proportional relationship.

2.3 Symmetry

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

SYMMETRY

 The dental midline is straight.

 The smile line follows the convexity of the lower lip
 The central incisors are symmetrical
 The gingival margins of the central incisors are symmetrical.
 Incisal embrasures gradually deepen from the central incisors to the canine.
 The incisal plane is either convex, sinuous, or a combination of both.
 Mesial tooth inclinations are more pleasing the distal inclinations.

ASYMMETRY

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

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

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

 The central incisors may slightly overlap the other or occupy a more facial position or may be

 slightly rotated facially.

 A central incisor may be more, mesially inclined than the others.
 The distal incisal angle of the central incisor may be bilaterally asymmetrical.
 Lateral incisor may differ bilaterally in shape inclination, abrasion, and gingival rotation their
margins do not need to be level.
  The labiolingual inclinations of the canines may be slightly asymmetrical.

2.4 Axial inclination (Fig.22&23)

Is the direction of teeth with respect to the central nwlline. There is a definite mesial inclination
of all anterior teeth as well as the premolars and first molars relative to the midline.

Equilibrium is realized around the central fulcrum. In the natural dentition, we notice a wide
range of deviation from the standard axial incisal inclination. In the presence of moderate and pleasing
axial deviation, these inclinations most often singularize and enhance the personality, provided an
equilibrium or a balance of lines has been achieved around the central fulcrum. Deviations beyond a
certain degree of equilibrium are invariably rated as unattractive. Also, when equilibrium of axial tooth
inclination has not been achieved in the dental composition, the resulting visual tension may also point
out a possible factor of occlusal instability.

Fig.19 The outline of the

Maxillary central incisor is a

combination of a circle, a Fig.20
rectangle and a triangle.
Fig.23
2.5 Tooth arrangement:

Anterior teeth, in achieving lip and associated muscle support, enable the fulfillment of esthetic,
phonetic and functional requirements. Phonetic methods use the functional reference of the maxillary
and mandibular anterior tooth relationships to assure naturalness in the dynamics of speech. Most
authors rely on various anatomic landmarks for the placement of anterior teeth. The position of the
incisive papilla could be used as a solid reference as it has been observed to be little affected by bone
resorption.

 The CPC line: (Fig.24) a line drawn from the tip of the canines invariably bisects the middle of
the incisive papilla in 92% of the cases. The distance from this line to the outer labial surface
averages 10.2mm.
 Ortman et al (Fig.25) stated that from the posterior border of the incisive papilla, this distance
averages 1245 mm, with a standard deviation of 3867mm.
 A similar statement was made in reference to the first palatal rugae, the end of which is located
1.5 to 2mm from the lingual surface of the canine.
 A number of clinicians (Fig.26) (Turbyfill WF, Dourdakis J. personal communications, May
1989) have observed a constant in the distance measured from the base of the sulcus to the tip of
maxillary incisor. This provides a good reference to the placement of this tooth in the vertical
plane.
 Arch form: (Fig, 27, 28&29.) The individual variations of the arch form have been arbitrarily
classified as square, ovoid and tapered with the multitude of combinations that nature endows. It
appears that each type of arch form assumes a certain type of tooth position. According to the
Academy of Dental Prosthesis, anterior teeth should maintain some of the irregularities
observed in nature. This is better achieved by tooth placement according to an arch form that
assures a natural variety

Fig.25
Fig.24 Fig.27
 Fig.31

2.6 Gradation (Fig.30&31) Fig. 30

When similar structures are aligned one after the other, they undergo a progressive visual
31
reduction of size from the nearest to the farthest.

The prerequisite of the "front-back progression" of the teeth is the alignment of the outline or
contour of the buccal surface, incisal 1/3rd, median 1/3rd, and, at a lower rate, the gingival 1/3rd, as
well as the alignment of the incisomesiobuccal Inclines. The presence of a poorly shaped tooth,
differences in tooth length, gingival disharmonies and colored restorations create problems with respect
to the gradation effect. The buccal corridor or lateral negative space between the buccal outline of
posterior teeth and the corner of the- mouth helps in achieving gradation effect in progressively altering
tooth illumination. The front-back progression is determined by arch form and a key element or key
tooth, usually the canine or the premolar, is a prerequisite for ensuring the visualization of the gradation
effect.

2.7 Dental morphology

Teeth have generally been defined according to their two-dimensional outline, but their
successful characterization depends on the evaluation and reproduction of three-dimensional characters.
2.7a Texture

We are able to evaluate texture optically through the amount of light reflected or deflected. The
characterization of the tooth surface is a function of two types of convexities and concavities:

 Anatomic grooves, facets and prominences that exist in various degrees on any tooth surface.
 The perikymatae, stippling and rippling that may affect the enamel surface.
The quality of an artificial tooth directly depends upon the blending of light effects that produce a
result similar to that produced by a natural tooth

2.7b Shape of teeth

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

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

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

Description of the average anatomic feature of anterior teeth is important as it provides the
dentist with basic geometric norms, without restricting the esthetic sense.

The influence of a number of authors like Wheeler, Stein, Gypsi, Dawson and Scharer contributed to
the design of the tooth morphologies.

2.7d Mesiodistal width (Fig.37)

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

2.7e Incisogingival height

This dimensional value is less critical than the mesiodistal width as it seems highly dependant
on clinical situations. Attention is only focused on tooth length when it passes a certain degree of
esthetic tolerance.

The primary determinants of incisal length are:

 Length and curvature of upper lip

 Patient preference

The accessory determinants of incisor length are'

 Posterior plane of occlusion

 Average anatomic crown length values for maxillary central incisor
In giving back full youth, disharmonies will seldom originate from tooth width or length but rather
from inappropriate color selection, which increases in saturation with the advancement of age.

The simulation of natural appearance that is advocated by the specialists of denture prosthetics is
clouded by the rule that the teeth in their length, and width should be related to the patient's age. As a
consequence, progressive anterior tooth wear is considered normal, until TMJ problems make both
dentist and patient aware of pathology, well present during the years but not recognized as such and left
untreated. Therefore, the restoration of anterior teeth in their youthful normality becomes a prerequisite
for the restoration of function.

2.7f Incisal profile

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

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

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

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

2.8 Contact points (Fig.40&41)

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

It is generally accepted to locate the contact between centrals at the most incisal 1/3rd, a point
that terminates as a long vertical interincisal line of contact. This line serves as a reference for
symmetry and balance of the two sides. If an imaginary line is drawn between the anterior contact
points, it forms a curvature that greatly reinforces the curve of the incisal line and the lower lip line.

The directional coincidence of contact, incisal and lower lip line provides cohesive forces to the
dentofacial composition. At the same time, the degree of curvature introduces segregative forces in the
composition.

2.8a Anatomy of the Contact Point

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

2.8b Embrassures or interdental spaces

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

Esthetics and accessibility of embrassures for oral hygiene are inversely proportional. In the
posterior area, wide open embrassures favor accessibility for oral hygiene and sufficient room for the
gingiva, but do not allow for lateral food impaction provided the contact is maintained. In all
circumstances, when a normal tooth structure exists along with adequate interproximal root proximity
and a sound periodontal state, maintenance of the embrassure space depends directly on the amount of
preparation, margin placement, fitness of restoration, emergence profile, interproximal tooth design and
location and width of the contact area.
 Fig.32 Fig. 33 Fig.35 Fig.36

Fig.37

Fig.39

Fig.41

Fig.40

3. GINGIVAL COMPONENTS

3.1 Gingival morphology

The gingiva begins at the mucogingival junction (linea girlandiformis ) and finishes at the tooth collar.
It is divided into free and attached gingival.

The free gingiva is divided into:

 Marginal gingiva: that surrounds the buccal and palatal aspect of the teeth in an average width
of 0.5-2.0mm.
 Interdental gingiva/papilla: Extension of the free marginal gingiva, the form and size of which
are determined by the contact relationship of the adjacent teeth and the width of the proximal
surfaces.

The attached gingival exhibits the typical orange-peel stippled appearance. The maintenance of a good,
healthy marginal periodontal tissue, providing a pleasing esthetic appearance, requires a minimal width
of 2mm of attached gingiva. Pigmentations are confined to attached gingiva.

3.2 Gingival contour

The normality of gingival contour is judged according to four subsidiary factors:

3.2a Embrassures

In healthy individuals, the gingival tissue blends into the tooth embrassure, which is totally filled from
buccal to lingual. Unfortunately, it tends to appear, usually following gingival recession or periodontal
therapy, by the development of a black triangle. Restoration of embrasures is crucial in esthetic
dentistry.

3.2b Gingival zenith (Fig.42)

The most apical point of gingival tissue is located distal to the long axis of the tooth on maxillary
central incisors and canines, while on the maxillary lateral incisors and mandibular incisors, it is located
along the long axis.

3.2c Ginqival heiqht (Fig.43&44)

Class I

In Class I occlusion tooth position, the marginal gingival tissue is at a parallel or symmetrical level on
both central incisors, a lower location on the lateral incisors and slightly higher and ideally symmetrical
on the canine.

. Class II

Average location of the gingival and co-ordinate tooth position in Class II or pseudo Class II, exhibits a
higher location of gingival height on lateral incisors relative to central incisors, with a slight overlap of
the laterals on the centrals

3.3 Gingival symmetry

Gingival symmetry of the central incisors requires special attention. Gingival symmetry between lateral
incisors and canines is not mandatory, and unilateral display of free gingival margin of a lateral incisor
or a canine in various smile positions is also esthetically acceptable.

Fig.42

Fig.43
Fig.44
4. PHYSICAL COMPONENTS (ILLUSIONS)

The art of creating illusions consists of changing perception to cause an object to appear different from
what it actually is. The use of optical concepts to create optical illusions may be the best way to solve
or hide an esthetically difficult situation. The control of the phenomenon of light reflection and color
contrast will provide us with means of creating illusions and thereby, re-establish proportions.

"The cardinal rule is that everything is relative to something else." (Fig.45)

The process of perception is an organization of sensory data (sight, hearing, taste and smell stimuli),
which are brought to the intellect where an answer is developed in combination with results from
previous experiences or beliefs that are unconsciously interpreted. Visual perception is a prerequisite
for esthetic appreciation in the same fashion that visual examination is also a routine in normal clinical
investigations.

Visual perception is: (Fig.46)

 Increased by increasing contrast

 Increased by increasing light reflection
 Decreased by increasing light deflection

4.1 Principles of illusions

 Principle of illumination: states that shadows create depth and light creates prominences.
Unidirectional, artificial light throws no shadows, therefore displays only length and width, whereas
multidirectional light throws shadows adding a third dimension of depth.

 Principle of lines: states that vertical lines accent length and horizontal lines accent width.
4.2 Law of the face

Suggests alteration of the silhouette form of the tooth, which in turn changes light reflection and creates
a perception of a different facial form.
The "face" of a tooth is that area on the facial surface of both anterior and posterior teeth that is bound
by the transitional line angles, which mark the transition from the facial to the mesial, distal, cervical
and the incisal surfaces. The "apparent face" is that portion of the face that is visible to the observer
from any single view. The law of the face implies making dissimilar teeth appear similar by making the
apparent faces equal, by creating similar transitional line angles. When the line angles cannot be
repositioned on a restoration, the portion of the tooth can be stained dark, promoting the effect that the
tooth is receding.

4.3 Altering the perception of the maxillary central incisor

These optical principles should be applied by means of tooth contouring and color manipulation.

 Initial situation (Fig.47,48&49)

3 labial prominences

Line angles

Cervical convexity

Vertical and horizontal lines or ridges

 Narrowing illusion (Fig.50&51)

Tooth contour modification:

Displace line angles mesially

Increase convexity of central prominences mesiodistally

Increase length of central prominence moderately

Increase facial embrassures

Highlight texture and gloss with vertical lines and ridges

Displace proximal contacts palatally

Rotate distal aspect lingually

Tooth colour modification:

Increase dark staining of interproximal areas

Applications:

To close diastemas

To decrease large pontic space

To control tooth proportions

 Widening illusion(Fig.52&53)
Tooth contour modification:

Displace line angles laterally

Decrease curvature of central prominence rnesiodistally / flatten facial outline

Decrease facial embrassures

Highlight texture and gloss with horizontal lines and ridges

Rotate distal aspect labially; overlap

Tooth color modification:

Decrease staining of interproximal areas

Applications:

To correct crowding (limited result)

To increase narrow pontic space

To improve tooth proportions

To correct elongated crowns after periodontal or implant surgery

 Shortening illusion (Fig.54&55)

Tooth contour modification

Adjust incisal incline lingually

Emphasize and displace cervical convexity coronally

Decrease length of central prominence

Flatten middle 1/3rd to broaden surface of light reflection

Highlight texture and gloss with horizontal lines and ridges

Tooth color modification

Darken gingival 1/3rd

Decrease interproximal staining

Applications

Asymmetry of maxillary incisors

Long pontics

To control tooth proportions

To correct elongated clinical crowns after periodontal or implant surgery

 Lengthening illusion (Fig.56)

Tooth contour modification

Flatten and displace cervical convexity apically

Flatten labial surface gingivoincisally

Increase length of central prominence

Round labial surface mesiodistally

Highlight texture and gloss with vertical lines and ridges

Tooth color modification

Lighten gingival 1/3rd

Increase interproximal staining

Applications

Asymmetry of maxillary incisors

To correct a short maxillary central incisor that cannot be lengthened surgically

4.4 Altering
perception
of tooth by
making
changes in
adjacent
tooth/teeth
 Fig.45 Fig.46

Fig.47 Fig.48
 Fig.49 Fig.50

Fig.51 Fig.53

Fig.54 Fig.56
Fig.55

COLOR
Perceiving and analyzing color is a skill that can be taught and one that can be improved with practice.
Color cannot be perceived without light, which is a form of electromagnetic energy visible to the eye.
The visible spectrum of light lies in a narrow band of 380nm to 760nm.

1. DIMENSIONS OF COLOUR

Color has 3 dimensions:

HUE CHROMA VALUE

 Hue: is the quality of sensation according to which an observer is aware of the varying
wavelengths of radiant energy. In Munsell's words, "it is the quality by which we distinguish 1
color family from another." The order of the physical hue is VIBGYOR, but within the visible
spectrum, there is no clear demarcation between discrete lines. The primary source of natural
tooth color is dentin and its hue is either in the yellow or yellow-red range.
In the Vita shade guide there are 4 hues

'A" for reddish brown

'B" for reddish yellow

'C" for' grayish

'D" for reddish-grey

 Chroma: is the dimension of color that defines the intensity or concentration of the hue. In
Munsell's words, "it is that quality by which we distinguish a strong color from a weaker one."
In teeth, it is dictated by the dentin and influenced by the translucency and thickness of enamel.
Pale colors have low chroma whereas intense colors have high chroma. E.g. in the hue "A" of
the Vita shade guide, A 1 has the lowest chroma, whereas A4 has the highest. Canines usually
have higher chroma than incisors in the same mouth.
 Value: is the relative blackness or whiteness of color. On a scale of black to white, white has"
high value", black has "low value" and midway between the black and white is medium grey
Value is the only dimension of color that can exist by itself. Value differences are more
noticeable and thus have more relative significance in a dental restoration than hue or chroma.
In the hue "A" of the Vita shade guide A 1 is the brightest while A4 is the darkest.
Evaluating dimensional differences

Color matching authorities state that hue differences are the easiest to detect and value differences the
most difficult. In the evaluation of value and chroma differences, education and training are needed.
Confusing value (degree of brightness) differences with chroma (color purity or saturation) differences
is common. To test value differences, squinting is recommended. This eliminates detail and reduces the
field of vision to a more achromatic (colorless) condition, making it easier to concentrate on value
differences. When two objects being compared look more different during squinting than with normal
viewing, a value difference is certain. Squinting is not a panacea for matching problems, but it provides
a starting point that can be applied to clinical practice.

2. PROPERTIES OF COLOR

 Opacity and translucency: (Fig.58&59) As light strikes a surface it is either totally reflected
(opaque), totally transmitted (transparent) or a combination of both (translucent). Translucent
objects transmit part of the incident light and scatter the rest. Translucency decreases with
increased scattering within the material. It is the three-dimensional spatial representation of hue.
Highly translucent teeth tend to be lower in value, while opaque teeth have higher value.
 Metamerism: The change in color perception of two objects under different lights is called
metamerism. Two objects with identical spectral distribution curves will always match
regardless of the illumination. When attempting to create different materials with the same
color, however, identical spectral distribution is difficult to achieve, resulting in metamerism.
Such objects appear to be of the same color under some lighting conditions, but not others.
Tooth structure, porcelain and other tooth colored restoration materials have different spectral
distribution curves. They should, therefore, be tested under three light sources: daylight cool
white fluorescent light and an incandescent lamp.
 Fluorescence: The emission of light by an object at a different wavelength from that of the
incident light is called fluorescence. The emission stops immediately on the removal of the
incident light. Teeth fluoresce with a stimulus in the blue spectrum of color i.e. 340nm to
410nm.
 Gloss: Gloss is an optical property that produces a lustrous surface appearance, thus reducing
the effect of color difference and increasing the brilliance.
 Fig.58
Fig.59

3. PERCEPTION OF COLOR

Perceiving and analyzing color is a skill that can be taught and one that can be improved with practice.
Color perception and shade selection are affected by several variables and involve many physical,
physiological and psychological aspects.

 Light source: The lighting environment makes a significant difference in the perception of color.
 If light of a certain wavelength is absent or deficient in the source of light, it cannot be reflected
to the observer even though the object might be capable of reflecting such light. Therefore, it is
essential to illuminate an object with full spectral lighting in order to assess its color correctly.
The dental operatory maybe illuminated with a combination of natural sunlight and artificial
light. It is imperative to establish similar lighting environment in the dental operatory and the
technician's laboratory so that there is a constant color purity of white light. Daylight, though
ideal, cannot be routinely used as it varies with time, atmospheric conditions and season.
The ideal color temperature for shade selection should be 5500K to 6500K

Color rendering index (CRI): The point where all hues are perfectly balanced is given a CRI of 100.
For dental shade matching a CRI of 90 or above is recommended.

Commonly used fluorescent tube lights emit color with a green tint that can distort color perception,
therefore color corrected operating lights and fluorescent tubes should be used.

Contrast ratio: The ratio between the task light and the ambient light is known as contrast ratio and
should be between 3: 1 and 10: 1.

The dental operatory should always be evenly and adequately illuminated with neutral grey or
pastel blue walls. Ceilings must have a Munsell value of 9 for maximum reflectance. Walls should
have a Munsell value of at least 7 and a chroma of less than 4.

 The object: The quality of the color of an object depends upon its ability to absorb, reflect or
transmit the light energy falling on it. The surrounding environment greatly influences the color
of the object.
 The observer (color vision) : The eye receives visual images through the reception of light,
which it directs to receptor cells, rods and cones, which convert this information and transmit it
to the brain for interpretation.
Cones are packed tightly in the foveal region, which is the center of most acute vision, but rods are
found away from the fovea and increase in numbers towards the periphery of the retina.

There are three types of cones, each containing a photosensitive pigment with a range of sensitivity
to which it will respond. The pigments respond selectively to the additive primary colors of blue
(445nm), green (535nm) and red (570nm), so the human visual system is able to receive color
 through the additive color system because the pigments convert light to color sensation.

On the other hand, achromatic vision is mediated by the rods. Value can be best appraised by
"looking off" the fovea and squinting. When the eyes are narrowed, the light admitted is diminished
and the focus becomes less acute. This favours rod function and the judgments of value are
enhanced.

Defective color vision

Normal color is called trichromatic vision as it is derived from three photosensitive pigments. Total
color blindness (monochromatism) is extremely rare; other less serious defects in color vision are sex-
linked and affect about 8% of the male population. The most common defects occur when the person
can see all three primary colors, but has a weakness or confusion in some area, usually the red or green
area. There are also types of defects where the person can see only two of the primary colors.

It is clear that color defects should be identified in dentists so that compensatory steps can be taken.

Negative after-image

The ability to perceive the correct hue is progressively diminished with time if one stares long enough.
As light of a particular wavelength strikes the cones sensitive to the stimulus, the photosensitive
pigments involved are depleted at a rate faster than regeneration can occur, making the eye less
sensitive to the hue range of that stimulus. The accuracy of shade judgments becomes rapidly less
reliable through this phenomenon termed "hue adaptation". Along with the waning ability to perceive a
given hue, the eye becomes more responsive to the complementary hues of the adapted range. E.g.
intense red lipstick can make teeth appear greenish by reducing red perception.

To overcome the problem in clinical situations, comparisons in shade selection should not exceed 5
seconds duration. The gaze should then be diverted to a card of a medium blue color to adapt vision to
blue and sensitize it to the yellow of the teeth. The eye can then continue to be an active receptor

4. SHADE SELECTION

Shade selection is both a visual and a cerebral process. For optimum results, it must follow a logical
sequence:
4.1 Basic shade

4.2 Basic shade variations

4.3 Enamel shade, translucency and location

4.4 Special effects

4.1 Basic shade

The basic tooth shade (or hue) must be evaluated by matching the center of the natural tooth with the
closest approximating shade tab. The first impression is the most important because spontaneity gives
the best results. When in doubt, the two closest matching shade tabs should be compared directly under
the natural tooth

 Shades in the "A" group are the closest yellow hues to red and are frequently encountered in
young individuals.
 Shades in the "B" group are closer to pure yellow, located on one extreme of the natural tooth
color space and represent only a fraction of natural hues. A false perception of yellow also
occurs when the natural tooth is observed in contrast to a pink or red background.
 Shades in the "C" group may be considered a subgroup of the "B" family because they have a
somewhat comparable hue but at a lower value. Therefore, they are frequently encountered in
middle aged and older individuals or in patients with tetracycline-stained teeth
 Shades in the "D" group are rarely encountered but maybe considered a sub group of the "A"
family because they have a somewhat comparable hue with a lower value.
Note: shades in the "C" or "D" group represent only isolated examples of lower value of a given hue of
the "B" or "A" group, and as such do not automatically provide the expected value when a "A" or ''B''
tab of a lower value is desired.

4.2 Basic shade variations

After the basic hue is determined, the next step is to detect its variations according to the location on
the tooth, the addition of the orange to the basic hue, or the incompatibility with standard shade tabs.

 Orange modification: various studies indicate that natural tooth color falls in either the yellow
or orange color space. The orange tonality is either expressed in the body of the tooth or is
 confined at the cervical aspect.

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

Uniform: The next most frequent category was nearly uniform shade distribution, resulting in a
monochromatic appearance.

Cervical third: Cervical variations may either correspond to the cervical aspect of the shade tab
or tab of another shade guide, or be perceived as more saturated, more orange, or lighter in
comparison.

Middle aspect: the clinician should determine whether the basic shade is uniform or whether
shade variations occur on the body of the tooth.

4.3 Enamel shade, translucency and location:

Once the hue and its variations are determined the quality and location of the enamel overlay must be
separately evaluated. Because it may range from whitish opaque to very transparent, it also affects the
value of the tooth. Teeth in young patients may have white shades with high value because of the dense
and highly reflective enamel. Teeth in middle aged and elderly patients may appear duller or more
orange because of the translucent or almost transparent enamel. Between these two extremes, enamel
assumes a semi-translucent quality.

Enamel of the natural tooth should be analyzed in terms of value and translucency. This evaluation may
either be made with conventional shade tabs, separate enamel tabs available from the manufacturer or
with customized fired enamel samples.

For maximum individuality in esthetic reconstruction, the opacity of the enamel overlay should
increase when proceeding from the central incisor to the canine.
Translucent enamel zones may stand out or less distinctly from the basic tooth color and have been
classified by Sekine et al into three groups

Type A: Translucent layer cannot be discerned and is distributed over the entire aspect of the tooth.

Type B: Translucent layer is present at the incisal aspect only.

Type C: Translucent layer is present at both the proximal and incisal aspects. Additionally, a halo at the
incisal edge is produced by total reflection of light within the confines of the incisal edge, resulting in
an opaque outline.

Opalescence

Is an important component of the perceived enamel color. It is caused by the scattering of light between
two phases, namely hydroxyapatite crystals and the enamel ground substance that have different
refractive indices. These crystals, acting as microparticles smaller than the wavelength of light, scatter
incident light. As a result, under incident light, longer wavelengths (orange and red) of light are
selectively transmitted through the tooth, whereas shorter wavelengths are reflected on the enamel
surface, producing the subtle bluish gleam characteristic of opalescence.

4.4 Special effects through staining

4.4a staining to alter shade

Objective Color of stain

Incisal edge
Blue, blue-violet, blue-green
To intensify translucency
(complementary)
hue lowers value and reduces chroma
Orange, orange-brown, brown
(complementary)
hues adjacent to one another, enhance
each
other. Also help to create third
 dimension)
Orange, red, yellow, grey, white (add
To decrease translucency
white sparingly)

Incisal-gingival blend
To increase incisal translucency Violet (for yellow body shade)
Blue (for brownish-orange body
shade)

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

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

4.4b Staining to add characterization:

Effect sought Color of stain

Random discolorations & White, orange, brown, blue, yellow

Labial mottling
Fissures and apertures
Sulci and proximal apertures
Worn enamel and exposed dentin
Exposed dentin of smoker
Incisal wear/erosion
Enamel cracks (young patients)
Check-lines
Grooves and pits (occlusal of
posteriors and lingual of anteriors)
Decalcification/hypocalcification
Cervical stain/gingival erosion
Existing silicate or composite
Stained outline
Restoration itself
Amalgam stain
Orange to brown (lighter yellow-
orange in young people; deeper burnt
orange as aging progresses
Orange to brown
Orange-brown or brown
Yellow-brown
Grey (distal), white (mesial), yellow,
black (for shadow effect)
Brown, black, yellow, orange
Brown, black, orange, blue
Opaque white, yellow, brown, grey
Brown, yellow, grey, lime green
Orange, brown, grey (should fade out
irregularly)
Opaque white, grey, yellow, brown
Grey, black, blue
Guidelines for shade selection

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

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

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

5. COMMUNICATING COLOR

If the principles of color are understood by both the technician and the dentist, communicating color is
much simpler.

The various methods of communicating color are:

 Modern shade guides:

When a tooth closely approximates a specific shade selection tab, but has characterizations or
deviations, aluminium oxide particles or emery discs are used to remove the shade tab glaze and
colorants may be applied, removed or modified until the proper effect is achieved.

 Custom shade guides:

According to Vryonis, approximately 85% shades can be matched with existing shade guides. The
remaining 15%, however, fall outside of the hue of standard tabs and require fabrication of a custom
tab. A custom shade guide, especially one having an expanded shade range can be very helpful.
Unlike most shade guides, a custom shade guide is made of the same material as the final
restoration, thus decreasing metamerism.

 Color sketches:
A set of colored pencils or fine-line markers can be very helpful in sketching color zones and
 variations in translucency. They require a narrative describing the meaning of each part of the
drawing.

 Photographs:
It is one of the best methods of communicating color. It gives a vivid description of the relative
translucency, opacity, color zones and incisal variations. The truest color will come from color
transparencies (slides). To be more effective the desired shade tab should be held adjacent to the
tooth and photographed. The intraoral camera is also a great help with shade communication.

ESTHETIC DIAGNOSIS AND TREATMENT PLANNING

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

successful esthetic dental treatment. The definitive treatment plan should address the treatment periods,
expenses, treatment sequencing and all aspects related to the function and maintenance of the
anticipated result.

Most esthetically motivated patients are eager to begin corrective treatment. Nevertheless, their
enthusiasm and, at times, self-diagnosis should not influence the dentist's esthetic diagnosis. It is
essential that the patient make an informed decision, after receiving a thorough explanation of his/her
condition and the ramifications of treatment, including the advantages and disadvantages of each
treatment alternative.

1. PATIENT HISTORY

Information should cover aspects of:

 Medical history: allergies, systemic disorders, previous surgeries etc.

 Dental history: past dental experiences, apprehensions, expectations etc.
 Personal and Social history
2. CLINICAL EXAMINATION
A clinical examination involves a thorough evaluation of facial and temporomandibular components
and assessment of occlusal relationship, periodontal attachment, teeth and intra-oral soft tissues.

 Facial components Face form, symmetry along the midline, relationships of various parts of the
face, position of lips and chin from frontal as well as lateral aspect, relationship of horizontal
and vertical references of face with respect to teeth and gums.
 TMJ: Palpated and auscultated for clicking, crepitus, hypermobility and deviation.
 Occlusal relationships' Occlusal pattern, type, contacts, disclusions and path during mandibular
movements
 Periodontal attachments: Plaque, calculus, gingival inflammation, amount of attached gingiva,
recessions, hyperplasia etc.
 Teeth: Caries, existing restorations, discolorations, wear facets, erosions etc.
3. ESTHETIC EVALUATION

The following analysis chart covers the facial, dentofacial, dental and functional analysis. In case any
abnormalities found in the soft tissues, hard tissues, TMJ and occlusal pattern, a thorough evaluation is
recommended before esthetic treatment planning.

Visual Analysis Chart

Facial
--

Face forms Square, round, oval, pear, tapered

Frontal perspective Nasio-Iabial groove Exaggerated

Mento-labial groove Normal
------

Vertical height Adequate

 More
Less

Lips Competent
Incompetent
Full

Dento-facial

Inter-pupillary line Incisal plane Parallel/not parallel

Gingival plane - Parallel/not parallel
Maxilla Canting / not canting

Upper lip line <1mm

Length of
maxillary incisors 1 - 4mm
visible at rest
>4mm

positio gingiv
Vertical of Low
n al
margins during smile Average
High

positio
Lower lip line Bucco-lingual of Touching
n
maxillary incisors Not touching
Slightly covered

Curvature of incisal plane Convex

Straight
Concave/reverse

Facial midline Dental midline Center

 Right of center
Left of center

Axis of dental midline Straight

Oblique

Moderate smile Gingival display <3mm

>3mm

Gingival patterns - Esthetic

Unesthetic

Vestibular space Less (expanded arch)

More (contracted arch)

Horizontal tooth
6/8/10/12 teeth
display

Function

Temperomandibular joint Joint clicking, crepitus, hyper-mobility, dislocation

Deviation while opening and closing, jerky

Mandibular joint
movements

Occlusion Antero-posterior plane Molar relationships

Canine relationships
Incisal relationships

Vertical plane Open bite

Deep bite
Edge to edge

Transverse plane Rotation

 Cross-bite

Phonetics

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

'P' or 'V' sound Incial edge of axillary Touch Inner

incior border
T ouches outer border of
lower
lip
Does not touch lower lip

Incisal
'M' sound <1mm
display
1-4mm
>4mm

4. SPACE ANALYSIS

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

5. PROFILE ANALYSIS

Patients with impaired dentofacial esthetics resulting from underlying skeletal problems can be
identified wit the use of profile analysis.

The patient’s profile can be:

 Straight / Orthognathic
 Convex / Retrognathic :
Due to: - prognathic maxilla - normal mandible

- Normal maxilla - retrognathic mandible

- Prognathic maxilla - retrognathic mandible

Features: - normal/increased / decreased lower facial height

- Lower lip trap, depending on the position of lower anteriors

Deep mentolabial groove

 Concave / Prognathic:
Due to : retrognathic maxilla - normal mandible

- Normal maxilla - prognathic mandible

- Retrognathic maxilla - prognathic mandible

Features: increase / decrease in lower facial height

-Maybe associated with habitual or pseudo Angle's Class III occlusal relationship.

6. DIAGNOSTIC AIDS
Study casts

Accurate study casts help give necessary inputs regarding intra-arch relationships like arch-length
versus tooth size discrepancies; alignments; angulations and inter-arch relationships like Angle's
classification, overbite, overjet, plane of occlusion etc. They also reveal functional relationships
involving centric and protrusive interferences, working side balancing side interferences, wear facets
etc.

Radiographs

IOPA and bitewing radiographs are used to detect interproximal caries, bone levels and quality,
periapical pathologies etc. Panoramic radiographs help to analyze pathologic lesions, impacted teeth,
teeth angulations etc. Radiovisuography has become extremely popular as it cuts down radiation by 80-
90% and multiple different angle views can be taken.

Intraoral camera

Is a powerful communication tool as it provides instant visualization of the patient's teeth. It has the
ability to easily transilluminate and photographically record hidden microcracks that could alter the
treatment plan.

Extraoral camera

Can record the whole oral frame including the smile window along with the smile line, lip lines,
negative spaces, midline shifts, gingival asymmetries etc. It plays an important role in records for
diagnosis and treatment planning, self-analysis, laboratory communication, patient management,
marketing, medico legal purposes and scientific documentation.

Magnification loupes

Help in accurate, detailed observation of tooth characteristics. Magnifying lenses of 2.5 diopter or
greater are extremely valuable diagnostic tools.

T-scan occlusal analysis

Is a computerized system that uses sensor technol.ogy to identify the location, timing and relative force
of occlusal contacts.

Periodontal charting

No part of the esthetic examination is more important than ascertaining the condition of the patient's
supporting bone structure. The periodontal ligament of each tooth is thoroughly probed in six locations
and charted. This can be done with either a traditional periodontal probe or an electronic device where
the data is recorded electronically using a voice activated system.

Computer imaging

Offers an unparalled method of visualizing your intended esthetic correction and the effect it can have
on the face. It helps patients to make suggestions and is a brilliant motivational tool.

7. INITIAL THERAPY

Initial therapy is required before esthetic treatment planning to arrest active pathoses, bring adequate
health to the dentition or give the patient relief from pain.

 Periodontal therapy:
-control of all periodontal inflammation through scaling and root planning

-replacement of overhanging restorations and crowns with improper margins and contact areas

-extraction of periodontally hopeless and non-strategic teeth

-relief from "trauma from occlusion" by conservative selective grinding and use of occlusal splints.

 Pulpal therapy:
endodontic procedures for asymptomatic and symptomatic teeth with necrotic pulps.

 TMJ disorders:
orthopedic appliance therapy for conservative management of TMJ disorders.

8. ESTHETIC TREATMENT PLANNING AND SEQUENCING

The definitive treatment plan should address the treatment period, expenses, treatment sequencing and
all aspects related to the function and maintenance of the anticipated result.

Several treatment plans can be proposed to the patient for esthetic correction. A problem list is made
related to the dentofacial problems enlisting individual solutions for individual problems and the impact
on the overall outcome.

A completed "Smile Analysis Form" can be discussed after the patient has reviewed the radiographs
with the dentist, to understand the patient's attitude and expectations.

S.No. Teeth Yes No

In a slight smile, with teeth parted. do the tips of your

1.
teeth show?

Are your two upper front teeth slightly longer than the
2
adjacent teeth?

3 Are your two upper front teeth too long?

4. Are your two upper front teeth too wide?

5. Are your upper six front teeth even in length?

6. Do you have space between your front teeth?

7. Do your front teeth protrude or stick out?

8. Are your front teeth crowding or overlapping?

9. When you smile broadly, are your teeth all one color?

10. Do your teeth have white or brownish stains?

If your front teeth contain tooth colored fillings, do

11.
they mater. The shade of your teeth?

12. Is one of your front teeth darker than the others?

13. Are your lower six front teeth straight?

14. Are your lower six front teeth even in appearance?

15. In a full smile, the back teeth normally show. Are your
back teeth free of stains and discolourations from
 unsightly restorations?

Do the necks of your teeth indicate erosion, a ditched-

16. in "V", that either can be seen or felt with your
fingernails?

When you smile broadly, does your top lip rise above
17.
the necks of your teeth so that your gums show?

Do your restorations - fillings, laminated and crowns -

18.
look natural?

Gums

Are your gums pink and "knife-edged", or are they red

19.
and swollen?

20. Have your gums receded from the necks of the teeth?

Does the curvature of your gums around each tooth

21.
create a half-moon shape?

Breath

Is your mouth free from decay or gum diseases that can

22.
cause bad breath?

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

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

9. FINAL CASE PRESENTATION

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

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

 Diagnostic wax ups on study casts

Probably the best method and one that has stood the rest of time is to prepare diagnostic wax-ups
and evaluate with the patient. This wax-up itself can be evaluated by the patient directly on the
diagnostic casts of the articulator and also intraorally with the use of acrylic overlays and acetate
matrices.

Computer imaging

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

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

PHYSIOLOGICAL/BIOLOGICAL CONSIDERATIONS

How good is a new smile if it doesn't last? However pleasing a dental restoration may appear, if it is
destructive to the biologic system, it is "ugly". Form and function are intimately intertwined. The
anterior region of the mouth presents a double challenge because it deals not only with the vital anterior
guidance system, but also the most predominant area of esthetics. Both objectives must be-satisfied.

The safest sequence of treating a mouth to bioesthetic function is as follows:

  Good diagnosis and treatment planning Patient education
 Treating the periodontium
 Stabilizing the craniomandibular relations in centric relation
 Restoring anterior teeth to bioesthetic function Restoring posterior teeth to natural physiologic
function
 Regular post-treatment maintenance

1. OCCLUSAL CONSIDERATIONS

Tooth morphology is totally genetic and not specific to race or gender. Nature produces sharp tooth
morphology on both anterior and posterior tooth surfaces, therefore it is necessary to have unworn
crown morphology for good esthetics as well as function. Natural crown morphology of both anterior
and posterior teeth develops early in life and is complete in every detail prior to tooth eruption into the
oral cavity. However, the other components of the gnathostomatic system, including the joints,
ligaments, muscles, maxilla, mandible and other cranial facial bones, continue to change significantly
long after the occlusal morphology of the teeth is complete. These changing components, such as the
temporomandibular joints, maxilla and mandible, are predetermined by genetics. The skeletal
components, however, are subject to environmental modification by factors such as abnormal posturing
of the mandible due to poor occlusion, face sleeping, abnormal swallowing, thumb-sucking and other
abnormal habits.

Natural and restored maxillary and mandibular teeth should have optimal functional contact
relationship resulting in the even distribution of load in static and dynamic positions leading to minimal
trauma of teeth and supporting structures.

1.1 Forces on the dentition

The peri-oral musculature and the tongue exert a constant force on the teeth. In full occlusion, the lower
lip and upper lip rest against the labial surface of the maxillary incisors. The lower lip helps retain the
maxillary teeth against the mandibular anterior teeth while the tongue holds the mandibular incisors
against the maxillary incisors in a state of equilibrium, referred to as the

"Neutral Zone". (Fig.60)This lip-tooth-tongue relationship helps produce a negative pressure seal
during mastication and swallowing as well as stabilization of teeth positions.

The direction and dissipation of load makes a difference in the forces exerted on the anchored root and
the surrounding bone. The process of directing occlusal forces through the long axis of the tooth is
called "Axial loading". Vertical load causes less stress compared to lateral load. A thorough
examination reveals that canines are best suited to accept horizontal forces during eccentric movements
as they have the best crown-root ratio and dense compact bone around the roots.

The maximum biting force is in the range of 30-50 psi for the incisors, 47-100 psi for the canines and
127-250 psi for the molars.

1.2 Mandibular movements:

The mandibular movements are influenced by the anatomy of the mandibular fossae and the condylar
head, shape of the articular eminences, musculature as well as the attachment and movement of the
articular discs.

 Functional movements: (Fig.61) The functional movements occur during the functional
activity of the mandible. They occur in all three planes. When the mandibular movements in all
three planes i.e. sagittal, horizontal and vertical are combined, we get a three-dimensional
"Envelope of Motion". The actual size of functional mandibular movement in the horizontal
plane takes place within a small diamond shaped area, only 3mm to the right, left and forward.
 Parafunctional movements.' are identified as a cause for occlusal wear and excessive forces.
They can be related to local factors like malocclusion, to systemic factors like cerebral palsy,
epilepsy and can also be stress and occupation related. Bruxism, clenching and parafunctional
tongue-thrust are important parafunctions which the dentist should consider during the
treatment planning stage.
1.3 Types of articulation

 Balanced occlusion: this occlusion has all teeth contacting in all excursions. It is primary a
denture occlusion. Naturally occurring examples are cases of advanced attrition.
 Mutually protected/canine-guided occlusion: when the mandible is moved in a right or left
laterotrusive excursion, only the maxillary and mandibular canines contact and efficiently
dissipate the horizontal forces while disoccluding the posterior teeth. Canines are best suited for
 this as they have large roots, dense surrounding bone and trigger fewer muscles during eccentric
activity, decreasing forces to the dentition and the TMJ.
 Group function: there are contacts between the maxillary and mandibular teeth on the working
side in eccentric movements. The non-working side completely disoccludes. This is the most
favourable alternative to canine guidance in case the canine is unavailable or periodontally
compromised. The most desirable group function consists of the canine, premolars, and
sometimes, the mesiobuccal cusp of the first molar.
1.4 Centric relation (Fig.62)

Is defined as the completely retruded position of the mandible with the condyles in their most superior
anterior position at any vertical rotational position of the mandible.

CR has been found clinically to be the best location for maximum intercuspation of teeth. In good
occlusion, all teeth in the mouth (anteriors and posteriors) make simultaneous contacts. Anterior teeth
should never contact harder than the posteriors or fremitus may be produced with possible endodontic
and periodontal trauma and/or interproximal separation of teeth. Normally, occlusal contacts on the
anterior teeth in CR are not broad, but rather two or three spots per tooth on the incisors and one on
each canine. The total contact area has been estimated to be about 4mm for the entire mouth, including
all of the anterior and the posterior teeth.

Stabilization of the craniomandibular relation in CR is important to the comfort, function and longevity
of dental restorations. .

1.5 Anterior overbite (Fig.63)

The maxillary anterior teeth are normally positioned labial to the mandibular anterior teeth. Both
maxillary and mandibular anterior teeth are inclined in a labial direction ranging 12 to 28 degrees from
a vertical reference line.

In well-related teeth, the vertical overbite of the maxillary central incisors ranges from 4-5mm when the
teeth are in full occlusion. The horizontal overbite of the maxillary incisors is 2-3mm in full occlusion

Variations can result from different developmental and growth patterns.

 When a person has an underdeveloped mandible (class II molar relationship), the mandibular
 anterior teeth often contact at the gingival third of the lingual surfaces of the maxillary teeth
(deep overbite).

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

Is the dynamic relationship of the lower anterior teeth against the upper anterior teeth through all ranges
of function. It literally sets the limits of movement of the front end of the mandible.

Anterior relationships must be determined with extreme preciseness because along with the discomfort
and look of artificiality, improperly restored anterior teeth may contribute to the destruction of the
entire dentition. When their position allows it, anteriors should be made to form a very stable stop for
the front of the mandible, thereby limiting its closing motion.

Anterior guidance is of two types:

 Incisal guidance (in protrusive-retrusive movements) : its primary importance is for proper
incising as well as rest positions and speaking functions.
 Canine guidance (in mediotrusive lateral movements) : the primary importance of the canine
guidance is to help prevent lateral eccentric posterior tooth interferences and allow the condyles
to move uninhibitedly along their border pathways in the fossae as well as to guide jaw closures
more vertically to load the posterior teeth in their long axis.
2. PERIODONTAL CONSIDERATIONS

A healthy periodontal environment with sufficient tissue volume to fill the interproximal spaces is an
essential element for ideal anterior esthetics. The tooth shape, incisogingival length, mesiodistal width
and the contact areas guide the gingival position in natural dentition.
2.1 Biologic width (Fig.67)

Gargiulo et al demonstrated in human autopsy specimens, a proportional dimension relationship

between the dentogingival junction and the other tooth-supporting tissues. The mean sulcular depth was
O.69mm, the mean length of the junctional epithelium was O.97mm and the connective fibrous tissue
attachment was 1.07mm (with a range of 1.06-1.08mm). Of these three tissue components, the
supracrestal connective fibrous attachment exhibited the least variability. The combined width of the
connective tissue attachment and the junctional epithelium averaged 2.04mm and has been called the
"Biologic Width".

The importance of not violating this physiologic dimension was suggested by Ochsenbein and Ross and
stressed by other authors. When margin placement impinges on the biologic width, gingival recession
or pocket formation and periodontal disease may ensue, depending on the thickness of the keratinized
gingiva and the underlying bone. Invasion of the biologic with may result in apical migration of the
dentogingival unit with gingival recession and may be self-limiting. With relatively thicker bone, it may
result in apical migration of the epithelial attachment and pocket formation.

Fig.61

Fig.60 Neutral Zone

 Fig.64 Fig.65

TREATMENT SUMMARY

BLEACHING

Treatment Time: Usually three to ten treatments,

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

Patient Maintenance: Thorough brushing after

Fig.66 meals is necessary to avoid plaque accumulation.

Smoking, as well as stain-causing foods such as
coffee and tea should be avoided.

Results of Treatment: Deep yellow and brown

stains can be considerably reduced, though teeth
may not be returned to natural color.

Average Range of Treatment Life Expectancy:

Indefinite, annual touch-ups may be required, but
treatment may last indefinitely.*

Fig.67
ADVANTAGES

1. Safe procedure.

2. Painless to adults.

3. No tooth reduction required.

4. No anesthetia necessary.

5. Least expensive of treatment alternatives.

DISADVANTAGES

1. Normal tooth color may not be restored.

2. Bleaching can cause discomfort in children

because of their large pulps

3. Only 75 percent effective in selected cases.

4. Extended treatment time may be necessary.

COMPOSITE RESIN BONDING

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

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

Results of Treatment: On-the-spot masking of stain.

Average Range of Treatment Life Expectancy: Average life expectancy is three to eight years. May
need repair or replacement more frequently.

ADVANTAGES

1. Painless.

2. Immediate (one-appointment) results.

3. Little or no tooth reduction.

4. Generally no anesthetia required.

5. Less expensive than porcelain laminates, crowning or "capping".

6. Avoids potential pulp or gum irritation that may occur when reducing tooth for full crown.

DISADVANTAGES

1. Can chip or stain.

2. If orthodontic treatment is required, it should be completed before bonding.

3. If orthodontic retainers are worn, holding wires should be Teflon-coated (stainless steel can cause
discolorations with some types of bonding materials).

4. Extreme care must be taken to avoid metals (such as hair pins) from coming into contact with
bonding.

5. Bonding has a limited esthetic life expectancy.

6. Certain types of stains (especially dark ones) cannot be covered well with bonding.

7. May involve minor tooth reduction to remove some of the stains.

8. Unless margins are finished perfectly, gum irritation can occur.

TIPS FOR PATIENTS WHO HAVE COMPOSITE RESIN BONDING

1. Do not chew ice.

2. Brush normally. Plaque must be removed daily. Ask your dentist about anti plaque mouthwashes and
toothpastes.

3. Floss teeth at least once daily, but pull floss out horizontally, not vertically.

4. Take multi-vitamins two times daily for one month before and after treatment if gum tissue is
inflamed.

5. Have your teeth cleaned at least three or four times yearly. Be certain that the hygienist is aware of
your bonded tooth or teeth and avoids using ultrasonic scaling or air abrasive on the bonded tooth
surfaces.

6. Make sure you are not grinding your teeth at night. If you are, have your dentist construct a bite
guard to avoid fracturing the bonding and to minimize damage to your bonded teeth as well as your
temporomandibular joint (TMJ).

7. Don't bite your fingernails. The force can crack the bonding.

8. Don't prick at a newly bonded tooth with your fingernail. You could pull open a small over-extension
and shorten the life of the material. If you feel a rough edge with your tongue, return to the dentist to
have the edge properly refinished.

9. Don't try your new teeth out too soon. Sometimes biting on the other side is not wise either. Go on a
soft diet for the first twenty-four hours. If your bite is not perfect, return to your dentist to have it
adjusted. Never try getting used to a new bite. The bite you are used to is usually correct.

10. To prevent staining, try to avoid, or keep to a minimum, coffee, tea, soya sauce, colas, grape juice,
blueberries and fresh cherries. And do not smoke.

11. To prevent fracture, avoid directly biting, with front bonded teeth, into the following foods: ribs,
bones (fried chicken, lamb chops, etc.) hard candy, apples, carrots, nuts, hard rolls, hard bread, bagels
or artichokes. Also try to avoid candy, mints or sugar, because acids produced by sugar can attack the
junction between tooth and restoration and cause stains and premature loss of the bonded restoration.

LABORATORY-CONSTRUCTED COMPOSITE LAMINATES

Treatment Time: Two visits. Impressions made after tooth preparation. On second visit, dentist will fit
and place laminates.

Patient Maintenance: Same as bonded tooth.

Results of Treatment: Attractive result that masks stain.

Average Range of Treatment Life Expectancy: Three to ten years.

ADVANTAGES

1. Can mask dark stains more esthetically than direct bonding.

2. No anesthesia usually required.

3. Can easily be repaired in the mouth if and when staining or chipping occurs.

4. More conservative-less tooth reduction than crowning.

5. Usually less expensive than crowning.

6. Color change possible.

DISADVANTAGES

1. Requires two visits.

2. Greater expense than bonded composites.

3. Can chip or fracture.

4. Can be an irreversible procedure if much enamel is removed.

5. Not as strong as porcelain laminates.

6. Greater wear than porcelain laminates.

PORCELAIN LAMINATES

Treatment Time: Two office visits. The teeth will be prepared and an impression made during the first
visit, which can take from one to four hours. The laminates will be fitted and inserted at the second
visit, which may also take the same amount of time. Expect to spend more time for more extensive
treatment.

Patient Maintenance: The teeth should be professionally cleaned three to four times yearly. Warn your
hygienist not to use ultrasonic scaling or air abrasive. Some precautions on eating habits: as with
bonding and crowning, take special care when biting into or chewing hard foods with your laminated
teeth, because they will not be as strong as enamel. Margins eventually need resealing.

Results of Treatment: A polished, natural-appearing result that effectively masks stains.

Average Range of Treatment Life Expectancy: Average life expectancy is five to twelve years.

ADVANTAGES

1. Less chipping than bonded restorations.

2. Etched porcelain provides an extremely good bond to enamel.

3. Wears less than the composite resin laminate.

4. Less stain so less chance of loss of color or luster.

5. More conservative - less tooth reduction than crowning.

6. Lasts five to twelve years as compared to plastics (three to eight years).

7. Gum tissue tolerates porcelain well.

8. No anesthesia may be required.

9. Color change possible.

DISADVANTAGES

1. More costly than conventional bonding.

2. More difficult for dentist to produce a polished surface after contouring in the mouth.

3. More difficult to repair if the laminate cracks or chips.

4. Can be an irreversible procedure if much enamel is removed.

BASIC TYPES OF ESTHETIC CROWNS

ADVANTAGES

Ceramo-metal*

 Strongest type of esthetic crown.

 Doesn't fracture or chip as easily as alternative esthetic type crown.
 Usually most economical esthetic crowns.
Ceramo-metal crown with porcelain butt joint*

 Esthetic.
 No metal shows from front.
 Strong.
All-porcelain or cast glass

 Most esthetic throughout crown life.

 No metal shows.
DISADVANTAGES

 Metal may be visible if tissue shrinks.

 Metal may be visible if tissue is thin.
 Metal may affect color of porcelain.
 Possible bluish tint of gum if gum tissue is thin and metal shows through.
 Metal usually visible from inside view only.
 Underlying metal may affect color of porcelain.
 Porcelain margin more susceptible to chipping than metal
 More costly to make
 Not as strong as ceramo-metal crown. Margin may be more susceptible to chipping.

CROWNING

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

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

Results of Treatment: Crowning can achieve the ultimate in shade control, tooth shape and size.
Average Range of Treatment Life Expectancy: The average esthetic life of the full crown is about
five to fifteen years. Life expectancy is directly proportional to three things: fracture, problems with
tissues, and the hidden danger of decay.

ADVANTAGES

1. Teeth can be lightened or whitened to any desired shade.

2. The dentist can improve shapes of teeth during this process.

3. Some realignment or straightening of teeth is possible.

4. Longest life of any restoration.

DISADVANTAGES

1. Ceramic crowns can fracture.

2. Crowning requires an anesthetic.

3. Original tooth form is altered (possibly involving the nerve).

4. If tissue shrinkage occurs, it can expose the junction between tooth and crown, allowing for the
possibility of an unsightly line.

5. Crowning is not permanent; there is limited esthetic life expectancy.

6. Crowning requires much greater expense than bonding.

POSTERIOR PORCELAIN INLAY/ONLAY

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

Patient Maintenance: Avoid biting hard objects in order not to fracture the porcelain. Professional
examination and cleaning two to four times per year. Daily flossing and brushing same as natural teeth.

Results of Treatment: Porcelain inlays/onlays can successfully achieve both esthetic and functional
results in restoring discolored posterior teeth.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is directly
proportional to problems with tissues, fracture and danger of decay.

ADVANTAGES

1. Highly esthetic.

2. No metal shows.

3. Strong once bonded to tooth.

4. Long lasting.

DISADVANTAGES

1. Can chip.

2. Greater cost over amalgam or composite resin.

3. Can wear opposing tooth if you grind your teeth.

4. Takes two appointments.

POSTERIOR COMPOSITES

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

Patient Maintenance: To keep resin-bonded restorations looking their best, you should have a
professional cleaning three or four times a year. Frequent cleanings remove food stains that
accumulate in microscopic spaces on the bonded surfaces of the teeth. These bonded surfaces are not
as strong as your enamel, so try to protect them by eating wisely. For instance, avoid most foods that
stain. Expect to have some repolishing or repair as necessary.

Results of Treatment: Posterior resin bonded composites can restore as well as esthetically match the
natural tooth
Average Range of Treatment Life Expectancy: Average life expectancy is three to eight years. May
need repair or replacement more frequently.

ADVANTAGES

1. Tooth colored.

2. More economical than crowning or porcelain inlay/onlay.

3. Produces an effective immediate seal from restoration and enamel surface that can bond weak or
cracked teeth together.

4. Permits less tooth structure reduction.

DISADVANTAGES

1. Wears faster than silver, gold or porcelain restorations.

2. Can fracture.

3. Shorter life expectancy compared to gold, silver,or porcelain.

4. Less suited for large cavities.

5. Can stain.

GOLD INLAY/ONLAY

Treatment Time: Usually two appointments one to two hours per

tooth.

Patient Maintenance: Normal brushing/flossing every day. Watch diet to avoid large amounts of
refined carbohydrates and chewy foods such as caramels and other candies that can eventually eat away
at the cement line and possibly cause decay under the gold restoration. Use fluoride mouth rinse and
toothpaste.

Results of Treatment: Best functional and longest lasting method of restoring teeth, but does tend to
show metal of large restoration. However, can be "antiqued" or sanded to dull gold reflectance.

Average Range of Treatment Life Expectancy: Five to twenty years.

AMALGAM

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

Patient Maintenance: Normal brushing and flossing every day. Limit refined sugars, such as candy,
which can attack margins, causing decay around and under fillings. Use fluoride mouth rinse and
toothpaste.

Results of Treatment: Still the most common of posterior filling replacements. Not as technique-
sensitive as other materials. Silver color may be visible depending on where and how large the
restoration is.

Average Range of Treatment Life Expectancy: Five to twelve years.

POSTERIOR CROWNS

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

Patient Maintenance: Normal brushing and flossing. Fluoride mouth rinse and toothpaste as
prescribed by your dentist. Same dietary restrictions as above for longest restorative life.

Results of Treatment: Crowning can achieve the ultimate in shade control, tooth shape and size.

Average Range of Treatment Life Expectancy: Five to fifteen years.

THE FOUR MOST POPULAR POSTERIOR RESTORATIVE MATERIALS.

1. GOLD INLAYS/ONLAYS

ADVANTAGES

 Longest lasting.
 Wears more like tooth structure.
 Will not fracture.
 Well suited for large cavities.
DISADVANTAGES

 Metal can show.

 Takes two appointments.
 More costly than amalgam or composite resin.
 Non insulative (conducts heat and cold).

2. SILVER AMALGAM

ADVANTAGES

 One appointment.
 Least costly.
 Predictability -Long life.
DISADVANTAGES

 Metal can show.

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

3. POSTERIOR COMPOSITES

ADVANTAGES

 Esthetic (tooth colored).

 Insulative.
 One appointment.
 Well-sealed to tooth (bonds to tooth structure).
 More economical than crowning or porcelain inlays.
DISADVANTAGES

 More costly than amalgam.

 Wear faster.
 Can stain.
 Can chip or fracture.
 Shorter life expectancy compared to silver, gold or porcelain.
 Less suited for large cavities.

4. PORCELAIN INLAYS/ONLAYS

ADVANTAGES

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

COSMETIC CONTOURING

Treatment Time: 15 to 60 minutes.

Patient Maintenance: Normal cleaning.

Results of Treatment: Teeth can appear straighter immediately after treatment.

Average Range of Treatment Life Expectancy: Indefinite.

ADVANTAGES

1. No anesthesia is required

2. Permanent solution

3. No maintenance

4. Most-conservative

5. Quickest solution

DISADVANTAGES

1. Too much reduction can alter the appearance of the smile line and may be unattractive

2. Bite may limit how much of the tooth can be removed

3. In rare instances sensitivity may be a problem

BONDING

Treatment Time: 1 to 2 hours per tooth.

Patient Maintenance: Professional cleaning three or four times a year. Eat wisely as these teeth can
chip easily. Floss in and pull it through rather than popping it out. Because staining or chipping can
occur, expect to have some repolishing or repair as necessary.

Results of Treatment: Most fractures and chips can be easily repaired with bonding.

Average Range of Treatment Life Expectancy: Five to eight years, with professional finishing once
every few years.

ADVANTAGES

1. No anesthesia required

2. Little tooth reduction required

3. Immediate results

4. Teeth can also be lightened

5. Less expensive than crowning

DISADVANTAGES

1. Can chip or stain

2. Bonding has a limited esthetic life

3. May not work for severe fractures

SPARE CROWNS

ADVANTAGES

1. Less expensive than starting over

2. You get instant replacement in case of fracture

3. You can save the cost of a temporary or an extra office visit

4. You could beat inflation; your crowns could cost more later.

DISADVANTAGES

1. Your initial cost is more

2. You may never need the extra set

3. Your tooth underneath may change drastically with time and then the spare crowns would not fit
properly

4. If your gum line changes around the neck of the tooth over the years, the spare crowns may be
useless

CROWNING

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

Patient Maintenance: Crowns are esthetically designed to look and feel like "real teeth." As with your
original smile, however, care must be taken to avoid tooth fractures. Yearly fluoride treatments may be
advised. Flossing every day is as essential with crowns as with natural teeth.

Results of Treatment: Badly fractured teeth may be repaired and reshaped as desired.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is directly
proportional to problems with tissues, fracture and danger of decay.

ADVANTAGES

1. The dentist can repair the chipped or fractured tooth

2. Teeth can be lightened to any shade

3. Some realignment or straightening of the teeth is possible

DISADVANTAGES

1. Crowns can fracture

2. Procedure requires anesthesia

3. Original tooth form is altered

4. It is not permanent

5. It is more costly than bonding

SOLUTIONS FOR SPACING PROBLEMS

 Orthodontics to reposition teeth

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

ORTHODONTICS

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

Patient Maintenance: Special care by the patient by cleaning daily and checkups on a scheduled
basis.
Retainers frequently have to be worn at night for many years, at least a few nights a week, possibly
indefinitely, to maintain tooth alignment. A water-powered cleaning device is also helpful if used
daily.

Results of Treatment: Spaces between teeth are closed.

Average Range of Treatment Life Expectancy: Generally permanent.

ADVANTAGES

1. Closes space between teeth

2. Permanent solution for most individuals

3. No tooth reduction required

4. May be the least expensive treatment (compared to crowning or bonding replacement)

DISADVANTAGES

1. Time-consuming (six to twenty-four months)

2. Teeth may return to original position if retainers are not worn

3. It is more difficult to clean teeth during treatment

BONDING

Treatment Time: One to two hours per tooth.

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

Average Range of Treatment Life Expectancy: Five to eight years. Professional refinishing once
every year.

ADVANTAGES

1. Little or no reduction of tooth structure

2. No anesthesia required

3. Reversible procedure

4. Economical, more so than crowning

5. Teeth can also be lightened

DISADVANTAGES

1. Can chip or stain more easily than crowns

2. Has limited esthetic life

3. Treatment may involve extra teeth to obtain proportionate space closing

4. Teeth may appear somewhat thicker

PORCELAIN LAMINATES

Patient Maintenance: The teeth should be professionally cleaned about three to four times yearly.
Some precautions on eating habits: as with bonding and crowning, take special care when biting into or
chewing hard foods with your laminated teeth, since they will not be as strong as enamel.

Treatment Time: Two office visits. The teeth will be prepared and an impression made during the first
visit, which can take from one to four hours. The laminates will be fitted and inserted during the second
visit, which may also take the same amount of time. Expect to spend more time for more extensive
treatment.

Results of Treatment: A polished, natural-appearing result that effectively closes spaces

Average Range of Treatment Life Expectancy: Four to twelve years.

ADVANTAGES

1. Easier to obtain proportionate closure of spaces

2. Less chipping than bonded restorations

3. Etched porcelain provides an extremely good bond to enamel

4. Wears less than the composite resin laminate

5. Less stain-less chance of color or luster loss

6. More conservative-less tooth reduction than crowning

7. Lasts four to twelve years as compared to plastics (three to eight years)

8. Gum tissue tolerates porcelain well

9. No anesthetic usually required

10. Color change possible

11. Less expensive than crowning

DISADVANTAGES

1. More costly than conventional bonding

2. More difficult for dentist to produce a polished surface after contouring in the mouth

3. More difficult to repair if the laminate cracks or chips

4. Can be an irreversible procedure if much enamel is removed

CROWNING

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

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

Results of Treatment: Crowning can achieve the ultimate in shaping teeth to fill
spaces.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is directly
proportional to problems with tissues, fractures and recurrent decay.

When to Crown: When tooth enamel is insufficient to bond

ADVANTAGES

1. Crowns can be shaped to esthetically fill gaps

2. Teeth can be lightened to any shade

3. Some realignment or straightening of the teeth is possible

4. Should last about twice as long as bonding

DISADVANTAGES

1. Can fracture

2. Requires anesthesia

3. Original tooth form is altered

4. May need to be replaced after five to fifteen years

5. More costly than bonding

CONVENTIONAL FIXED BRIDGE

Treatment Time: Two to four weeks

Patient Maintenance: Daily cleaning under bridge with floss threaders.

Results of Treatment: Esthetic replacement of lost tooth or teeth.

Average Range of Treatment Life Expectancy: Five to fifteen years.

ADVANTAGES

1. Longest life

2. Easy to clean

3. Improves your bite

4. Helps prevent movement of adjacent and opposing teeth

DISADVANTAGES

1. Difficult to match shade of porcelain

2. Costs more than cantilever

3. More tooth reduction than cantilever or resin bonded bridge

4. May be difficult to make look natural in cases of ridge or gum loss

CANTILEVER FIXED BRIDGE

Treatment Time: Two to four weeks

Patient Maintenance: Must clean under bridge. Easier to use floss threaders.

Results of Treatment: Esthetic tooth replacement

Average Range of Treatment Life Expectancy: Five to fifteen years average life.

ADVANTAGES

1. Less tooth structure reduced because fewer teeth required

2. Less expensive than conventional bridge

3. More natural separation possible between teeth

DISADVANTAGES

1. Less structural support

2. Unless the bite is perfectly balanced, too much torque can damage the replacement tooth

RESIN-BONDED FIXED BRIDGE

Treatment Time: Two to four weeks.

Patient Maintenance: Same as for conventional bridge. Daily cleaning under bridge with floss
threaders.

Results of Treatment: Tooth replacement without reducing other teeth.

Average range of treatment life expectancy: 5 to 10 years.

Treatment Time: Four to eight weeks.

ADVANTAGES

1. Less expensive than conventional bridge

2. No anesthesia required

3. Less tooth reduction

DISADVANTAGES

1. Less ability to alter shape and sizes of teeth

2. Tissue can shrink around gum, leaving spaces between teeth

3. Metal backing may show through if the teeth are thin

4. Teeth to which the bridge is attached must be in excellent condition

5. May not last as long as a conventional bridge

CONVENTIONAL REMOVABLE BRIDGE

Treatment Time: Four to eight weeks.

Patient Maintenance: Must remove bridge and clean after eating.

Results of Treatment: Least expensive way to replace missing teeth.

Average Range of Treatment Life Expectancy: Five to ten years.

ADVANTAGES

1. Less expensive than fixed bridges.

2. Helps to balance bite and increases chewing efficiency by replacing missing teeth

3. Prevents movements of adjacent and opposing teeth

DISADVANTAGES

1. Attachment may create possible wear and stress on supporting teeth

2. May not be as esthetic as a fixed bridge

PRECISION-ATTACHMENT REMOVABLE BRIDGE

Treatment Time: Four to eight weeks.

Patient Maintenance: Requires regular cleaning and adjustments.

Results of Treatment: Removable bridge is less obvious.

Average Range of Treatment Life Expectancy: Five to ten years.

ADVANTAGES
1. Clasps are hidden

2. Superior retention

DISADVANTAGES

1. More expensive than clasps

2. Attachments can break

3. Attachments can wear

OVERDENTURE

Treatment Time: Four to eight weeks.

Patient Maintenance: Requires daily cleaning and periodic adjustments.

Results of Treatment: Hides the fact you are wearing a removable bridge.

Average Range of Treatment Life Expectancy: Five to ten years.

ADVANTAGES

1. Saves roots

2. Improves chewing ability

3. Better fit and retention as compared to normal denture

4. Less stress to supporting ridge tissue

5. Provides a good transition to a full denture

6. Allows the patient to retain some tactile sensation

DISADVANTAGES

1. Attachment can break

2. More costly than conventional denture

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

IMMEDIATE DENTURE

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

Patient Maintenance: Cleaning after meals to remove and prevent stains on dentures. Check probable
gum shrinkage with your dentist. Requires relining.

Results of Treatment: Can duplicate or improve your tooth color, form and tooth arrangement.

Average Range of Treatment Life Expectancy: Usually no more than six months, but with a reline at
approximately three months, can last much longer

ADVANTAGES

1. You do not have to be seen without teeth

2. Helps keep ridge protected during healing following extractions

3. Easier transition to final denture

4. Can act as final denture

DISADVANTAGES

1. May require a final denture to be made

2. Possible added expense

3. Requires relining
4. May require frequent adjustments

FULL DENTURE

Treatment Time: Two to four weeks

Patient Maintenance: Cleaning after meals to remove and prevent stains on denture.

Results of Treatment: Esthetically pleasing results are possible.

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

ADVANTAGES

1. Maximum esthetics possible

2. More youthful appearance obtainable

3. Supports lips and cheeks

4. Can improve speech

DISADVANTAGES

1. Less chewing efficiency

2. Retention may be a problem

3. Needs maintenance

4. May need to be replaced every five to ten years

5. May impede speech in some instances

IMPLANTS
Treatment Time: Surgical placement time per implant is approximately one hour depending on the
complexity of the procedure. Healing is approximately three months in the lower jaw and six months
in the. Upper jaw while the implant permanently attaches to the bone. After healing, another
appointment may be necessary to uncover the implant and place a healing cap so your dentist can
construct a final crown.

Patient Maintenance: Daily flossing and home care as instructed by your dentist. Professional
cleanings four times per year. Exam by restorative dentist at least once a year.

Results of Treatment: Best approximates having your own natural tooth (or teeth). Provides tooth that
is natural appearing and individually functioning. Avoids unnecessary tooth structure removal on
natural adjacent teeth.

Average Range of Treatment Life Expectancy: Once successfully integrated into the bone, the
implant can last indefinitely, barring infection.

COSMETIC CONTOURING

Treatment Time: About one hour.

Patient Maintenance: Normal brushing and flossing.

Results of Treatment: Immediate reshaping of tooth structure makes crowded teeth appear the
appropriate size.

Average Range of Treatment Life Expectancy: Indefinite.

ADVANTAGES

1. Less expensive than other forms of esthetic treatment

2. Permanent results

3. Immediate problem correction

4. Minimum treatment time

5. Generally painless; requires no anesthesia

DISADVANTAGES

Teeth are not repositioned

2. Improvement may be limited by functional consideration

3. Possibly some discomfort for children with large pulp canals

4. No improvement in color

BONDING

Treatment Time: One to two hours per tooth.

Patient Maintenance: Professional cleaning three to four times yearly. Eat wisely-these teeth can chip
easily. Floss in and pull it through rather than popping the floss out. Expect some chipping or porosity
to eventually occur requiring a repair.

Results of Treatment: Straighter teeth in one appointment.

Average Range of Treatment Life Expectancy: Five to eight years.

ADVANTAGES

1. Conservative because there is little or no reduction of tooth structure

2. Reversible procedure

3. More economical than laminating or crowning

4. No anesthesia required

5. Teeth appear straighter

DISADVANTAGES

1. Does not reposition the tooth

2. The gums can become inflamed because of the crowding; in this case the basic problem is not
corrected

3. Needs to be redone more often

4. Can stain or chip more than crowns

5. Teeth may appear some what thicker

PORCELAIN LAMINATES

Treatment Time: Two office visits. The teeth will be prepared and an impression made on the first
visit, which can take from one to four hours. The laminates will be fitted and inserted at the second
visit, which may take the same amount of time. Expect to spend more time for more extensive
treatment.

Patient Maintenance: The teeth should be professionally cleaned about three to four times yearly.
Some precautions: as with bonding and crowning, take special care when chewing hard foods or biting
into foods with your laminated teeth, to avoid chipping or potential fracture.

Results of Treatment: Polished, natural-appearing results that can make teeth appear straighter.

Average Range of Treatment Life Expectancy: Four to twelve years

ADVANTAGES

1. Less chipping than with bonded restorations

2. Etched porcelain provides an extremely good bond to enamel

3. Wears less than the composite resin laminate

4. Less stain-does not lose color or luster

5. Can make more proportional results because they are constructed in lab

6. Lasts four to twelve years, as compared to plastics (three to ten years)

7. Gum tissue tolerates porcelain well

8. No anesthetic usually required

DISADVANTAGES

1. More costly than conventional bonding

2. More difficult to repair if the laminate cracks or chips

3. May eventually need repair or resealing of the margins if the cement washes out or debonds.

CROWNING

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

Patient Maintenance: Care in biting hard objects to avoid fracturing the crowns. Fluoride treatments
once yearly along with the use of fluoride toothpaste and flossing every day.

Results of Treatment: Crowning can achieve the ultimate esthetic results in reshaping overly crowded
teeth.

Average Range of Treatment Life Expectancy: Five to fifteen years. Life expectancy is directly
proportional to problems with tissue, fracture, and the danger of decay

ADVANTAGES

1. Teeth can be lightened to any shade

2. Takes less time than orthodontics

3. Crowned teeth stain less than bonded teeth

4. Longer life than composite resin bonding or porcelain laminates

5. Offers greatest latitude in improving tooth form

DISADVANTAGES

1. Can fracture

2. Requires anesthesia

3. Altered tooth form

4. Is not permanent; may need to be replaced after five to fifteen years

5. More costly than contouring or bonding

6. Is irreversible

7. May trigger pulp irritation in rare instances

8. May induce tooth sensitivity for a short time

ORTHODONTICS

Treatment Time: Six to thirty six months.

Patient Maintenanc:. Special attention to daily cleaning; adjustment check ups every three to four
weeks. Retainers will need to be worn at night indefinitely

Results of Treatment: Crowded and overlapped teeth can be straightened.

Average Range of Treatment life Expectancy: Generally a permanent treatment, but will usually
require wearing a retainer at least a few nights weekly.

ADVANTAGES

1. Can straighten misaligned teeth

2. Permanent solution for most individuals

3. Little or no tooth reduction required

4. May be less expensive than laminating, crowning or bonding, depending on the number of teeth
involved

5. Improved tissue health due to better cleaning access

DISADVANTAGES

Time-consuming (six to thirty-six months)

2. Teeth may return to original position if retainers are not worn

3. May take a few weeks to get used to appliances

Best advice: With your dentist, develop a master treatment plan before starting orthodontic
therapy. Be sure to include other treatment that may become necessary after orthodontic therapy
is completed.

COMPARATIVE TREATMENTS OF OPEN BITE

1. ORTHODONTICS

ADVANTAGE:

 Will improve ability to bite.

2. ORTHOGNATHIC SURGERY

ADVANTAGES

 Can improve facial esthetics

 May be only method available to correct deformity Results are usually permanent
DISADVANTAGES

 General anesthesia required

 Jaws may require fixation following surgery; limited
 jaw opening for the first several weeks
 Requires orthodontic treatment as well

COMPARATIVE TREATMENTS OF CLOSED BITE OR DEEP OVERBITE

1. ORTHODONTICS (DEEP OVERBITE)

Most preferable

Longest lasting

Can help

2. ORTHOGNATHIC SURGERY

Treatment Time: One to three months.

Patient Maintenance: Meticulous daily care of the mouth and teeth while the jaws are wired together.

Results of Treatment: Usually jaw problems and facial esthetics are improved by rearranging the jaw

bones and possibly adding implants, removal of fatty tissue, etc.

Average Range of Treatment Life Expectancy: For the most part, the treatment is permanent.

Cost: Several hundred to several thousand dollars, depending upon the treatment.

ADVANTAGES

1. Some jaw problems can be treated only by surgery

2. The procedures are usually accomplished in one or two visits at either a hospital or office surgical
suite

3. Although surgery can be costly, it may be covered by insurance

4. In most cases, self image is greatly improved, which may help relationships,career advancement and
quality of life

DISADVANTAGES

1. Surgery is required

2. Jaws may be wired together for six to eight weeks

3. Surgery may be costly, especially if not covered by insurance

4. Facial swelling and discomfort, with associated inconveniences, may last several weeks

5. May cause a negative personality change in unstable individuals

6. If plastic implants are used, they may become infected or shift

7. Facial numbness may result temporarily or permanently

HOW TO AVOID AN AGING SMILE

1. Watch for unnatural wear. It ages the smile.

2. Avoid bone and gum loss. Spaces between the teeth can give an older look to the smile. Take proper
oral hygiene seriously and request frequent periodontal evaluation from your dentist.

3. Replace fillings when necessary.

4. Don't let your crowns or bridges age you. If they are worn down, replace them.

5. Have any discolored teeth corrected. Staining makes you look older.

6. Replace any missing teeth as soon as possible. Missing teeth can cause your bite to collapse and
tissues to sag.
7. Correct your bad bite. As you age, the bad bite tends to become more pronounced. It's never too late
to have it corrected!

PREVENTION: THE BEST WAY TO FIGHT THE YEARS

You can keep your smile intact for a lifetime. Good oral hygiene-including tooth brushing, flossing and
regular visits to the dentist-will help keep teeth, gums and bone in good health.

Proper tooth brushing is one of the best ways to prevent tooth loss and other problems. If you're
not sure that you're brushing correctly, ask your dentist to show you how. Although a loss of tooth
structure due to mechanical wear is inevitable, incorrect tooth brushing often accelerates this process.
You may also want to purchase chewable disclosing tablets that allow you to see the plaque you missed
by revealing those areas in red.

You should also consider purchasing a rotary cleaning device with the advice of your dentist.
Research has shown that many people can improve their tooth cleaning ability with automatic tooth
brushes.

Also choose a dentist who offers an aggressive program of preventive maintenance. This should
include two to eight professional tooth cleanings per year, proper home care instruction, monitoring of
plaque control and referral to specialists such as periodontists when needed.

Finally, don't neglect to replace teeth that are lost. Failure to do so can result in more extensive-
and expensive-dental treatment in the long run than replacing them. Leaving a space in the back of the
mouth can lead to gum disease or throw off the bite by shifting chewing pressure to other teeth. This, in
turn, can cause the front teeth to shift. In fact, newly developed spaces between front teeth are often the
result of missing back teeth, so don't let it happen.

Never have your teeth extracted if there is sufficient bone to save them, even if only a root
remains. You will chew better-and look better-if you restore, rather than replace your natural teeth.

If your bone is diseased, periodontal surgery can often allow you to save your teeth. And your own
good roots are always better "implants" than artificial ones.

THE BEST WAY TO LOOK YOUNGER

The best way to obtain a more youthful smile is by combining the advantages of cosmetic dentistry,
plastic surgery and cosmetology-in that order.

First, improve your smile. Make sure it looks healthy and younger. Next, if you're concerned about
sagging facial tissue, consider plastic surgery. And finally, don't forget that a new hairstyle and updated
makeup can provide the finishing touches (see p. 297).

NEVER STOP CARING

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

REVIEW OF LITERATURE

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

2. Krajicek OD.22 (1962) Natural appearance is one of the more easily achieved objectives in complete
denture construction. The overall appearance of the denture is important, but only to the extent that it
contributes to a natural appearance and function of the face and lips. Practical guiding principles have
been suggested which are designed to break the appearance barrier and place this phase of
Prosthodontics on a sound basis.
3. Martone AC.32 (1962) An understanding of the muscles of facial expression is important to
successful complete denture construction. These muscles may be observed at work by the dentist when
he first views his patient and that patient begins to speak. An understanding of its prosthodontic
significance enables the dentist to employ post operative vision in the treatment planning stage which
can minimize denture failures. Prosthodontic treatment must be in terms of all of the functions
performed within the mouth region. In recognition of this, the present study was conducted to (1)
consider the role which the facial muscles play in expression. (2) analyze these muscles in terms of the
expressions of various emotions, and (3) evaluate their prosthodontic significances. Certain suggestions
have been made as to the role muscles of facial expressions may play in non-masticatory movements of
the mandible.

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

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

6. Hirshberg SM.18 (1972)

a. Oral hygiene exerts a more important influence on the health of the gingiva and mucosa adjacent to
fixed prosthesis than does the height of the embrasure.
b. Poor oral hygiene causes inflammation of the interdental gingiva, mucosa and filling in of the
embrasures. Even with ideal oral hygiene, there is a slight increase in the size of the interdental gingiva
and mucosa.

c. The oral mucosa is more likely to remain healthy under spheroidal or modified spheroidal pontics
than under ridge lap pontics.

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

8. Lombardi RE.26 (1974) The purpose of this article is to suggest a method of classification of esthetic
errors in tooth arrangement. Most tooth arrangement errors fit into an outline based entirely upon two
factors: (1) the relationship between the dental composition (the denture) and its background (the
patient) and (2) the relationship of the various elements within the dental composition.

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

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

11. Lombardi RE.27 (1977). Factors mediating against excellence in dental esthetics have been
classified and enumerated in this article. A formula for producing unaesthetic prostheses can be
hypothesized as follows: Educational de-emphasis + Lack of research + Technical orientation +
Technical tradition + Delegation (abdication) + Poor economics + Fatigue + Poor office design +
Convention + Conditioning + Schemata leads to POOR DENTAL ESTHETICS. It is postulated that a
formula for excellent dental esthetics can be produced by reversing these factors: Altered schemata +
Deconditioning + Altered convention + adequate office design + Elimination of fatigue + Favorable
economics + Personal participation + Research + Educational emphasis leads to ESTHETIC
EXCELLENCE.

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

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

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

2. A description of the pathways of posterior cusps during lateral contact gliding movement must
consider three simultaneously acting guidance factors: (a) the nonworking condyle pathway, (b) the
amount of Bennett movement or the working-side condyle displacement, and (c) the anterior guidance
or working-side tooth contacts.
3. A Bennett movement of 2.5 to 3.5 mm caused a dramatic flattening of lateral movement pathways of
the molar cusp as seen in the frontal plane. The steepness of neither the anterior guidance nor the
nonworking condylar pathway had much influence on the molar cusp pathway in the presence of this
excessive Bennett movement.

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

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

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

15. Vig RG, Brundo GC.54 (1978) A survey has been presented that correlates measurements of upper
lip type, sex, race, and age of dentulous patients with the amount of exposure of the maxillary and
mandibular anterior teeth with the lips gently parted and in the resting position. Perhaps the most
interesting finding was the gradual reduction in the amount of maxillary central incisor exposure with
an increase in age, accompanied by a gradual increase in the mandibular tooth exposure. The
importance of the amount of mandibular teeth seen in complete dentures has not been sufficiently
emphasized in previous literature.
16. Miller EL, Bodden WR Jr, Jamison HC.36 (1979) This report presents the results of an original
investigation designed to determine (1) the prevalence in the natural dentition of a maxillary midline
located in the exact middle of the mouth using the philtrum as the most reliable guide and (2) the
percentage of people in whom the maxillary and mandibular midlines precisely coincide with each
other. Results indicate that the midline is situated in the exact middle of the mouth in approximately
70% of people and that the maxillary and mandibular midlines fail to coincide in almost three fourths
of the population.

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

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

19. Mavroskoufis F, Ritchie GM.34 (1981) A investigation of 64 Angle Class I, skeletal Class I dental
students showed that the interalar nasal width is a reliable guide for selecting the mold of anterior teeth,
and that the incisive papilla provides a stable anatomic landmark for arranging the labial surfaces of the
central incisors at 10 mm anterior to the posterior border of the papilla. The mesiodistal width of the set
of anterior teeth (four incisor and the mesial halves of the canines) should be determined by adding 7
mm to the patient's nasal width (Fig. 8). The tips of canines on the horizontal plane, should be set on a
line which passes through the posterior border of the incisive papilla (Fig. 9). The distance between
them should equal the patient's nasal width, so that from the frontal view they would each seem to lie
on a perpendicular line drawn from each of ala of the nose.

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

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

22. MacArthur DR.29 (1987)

(1). For all samples, men had larger central incisors than women.

(2). The mean mesio-distal diameter for permanent maxillary central incisors was similar for both the
orthodontic and the mixed dentition samples.

(3). Mesio-distal and incisal tooth wear results in narrower central incisors in older age groups.

(4). The size of artificial central incisors is generally appropriate for the senior population.

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

24. Burckett PJ, Christensen LC.3 (1988) The results of this study indicate that it is difficult to
correctly age and sex by using anterior teeth as a guide. The difficulty in estimating age and sex in
dental patients is that they do not always fall in set patterns. Teeth do tend to darken with age but, this is
not always true. Older dentitions sometimes show minimal wear and some younger dentitions can show
moderate to excessive wear. The position of the maxillary lateral incisors does not always enhance male
and female characteristics. Perhaps the best method to select denture teeth for a patient is to place more
consideration on previous dentures and photographs and less on the age and sex of the patient.
25. Grove HF, Christensen LV.17 (1988) Fifty dentate maxillary casts, obtained from thirty-four males
and sixteen females, were mounted in the three-dimensional co-ordinate system of a contour meter. A
transverse line of reference (x-axis) was drawn through the distal contact points of the maxillary
canines, at a right angle to the y-axis which passed through the contact points of the maxillary central
incisors. Relative to the canine-to-canine baseline, the locations of the lateral borders of the right and
left first primary rugae were determined. The rugae were distributed on both the anterior and posterior
sides of the baseline, and the anterior and posterior distances from the baseline were on the average
about 1 mm. The age of the subjects, ranging from 12 to 52 years, appeared to be unrelated to the
frequencies of anteriorly and posteriorly positioned rugae. Right and left first primary rugae, located on
the anterior side of the baseline, showed a minute asymmetry in their topography. By contrast, there
was topographical symmetry when the rugae were located on the posterior side of the baseline.

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

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

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

29. Magne P, Magne M, Belser U.31 (1999) With the evolution of adhesive dentistry and the increasing
use of porcelain veneers, single-unit crowns generally are restricted to the replacement of pre-existing
full-coverage crowns and the restoration of nonvital and/or severely damaged teeth. Porcelain-fused-to-
metal restorations are still widely used to generate single-unit crowns and fixed partial dentures.
Collarless metal-ceramic restorations represent the most successful evolution among efforts to meet
maximum esthetic requirements using porcelain-fused-to-metal restorations. Extended metal
frameworks and opaque aluminous ceramic cores are associated with unpleasant optical effects in the
soft tissues surrounding such restorations. This problem is particularly evident in the presence of the
upper lip, which can generate an "umbrella effect" characterized by gray marginal gingivae and dark
interdental papillae. Based on the concept of the biologic width, a systematic approach is proposed for
the elaboration of an "esthetic width," including: 1) positioning of preparation margins; 2) reduction of
the metal framework; and (c) appropriate marginal design of porcelain-fused-to-metal restorations.
Strategic features of pontics and a specific interdental design are suggested to compensate for deficient
anatomical features of the soft tissue and the edentulous ridge.

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

CLINICAL SIGNIFICANCE: This article considers a bilateral analysis of apparent individual tooth
width as a percentage of the total apparent width of the anterior segment and proposes the concept of
the Golden Percentage as a more useful application in diagnosing and developing symmetry,
dominance, and proportion for esthetically pleasing smiles.

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

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

METHOD AND MATERIALS: Computer-manipulated images of the 6 maxillary anterior teeth were
generated from a single image and assigned to 5 tooth-height groups (very short, short, normal height,
tall, and very tall). For each group, 4 images were generated by manipulating the relative proportion of
the central incisors, lateral incisors, and canines according to the proportions 62% (or "golden
proportion"), 70%, 80%, and "normal" or not further altered. The images were randomly ordered on a
web page that contained a form asking for demographic data and fields asking for a ranking of the
images. Dentists were asked via e-mail to visit the web page and complete the survey. The responses
were tabulated and analyzed with repeated measures logistic regression with the alpha at 0.05. A subset
of North American respondents was chosen for further analysis.

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

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

32. Gillet D, Miquel JL, Jeannel A.14 (2002) The aim of this study was to evaluate the importance of
the dental aesthetic for the patients, the dental surgeon and the dental teachers by the study of the
consultation reason, the complaints, the post-university congress program, the practical program of the
dental students and the programs of the IADR congress. It appears that in odontology, patients ask
strongly for aesthetic care, in consultation and litigation. The content of congress and professional
literature shows that dental surgeons answer to that request. Only the practical teaching was a bit less
but it was recently modify. The research workers are also very interesting for aesthetic care.

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

CLINICAL SIGNIFICANCE: Dentogenics provides an approach to esthetics in prosthodontics that

enables the dentist to create a restoration in harmony with the patient's objective personality. This
concept considers gender, age, and personality to restore the patient's dignity and unique individuality
that has been missing in far too many prostheses.

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

CLINICAL SIGNIFICANCE: Integrating facial guidelines with the dental composition using a grid
highlights deviations from the ideal. It thereby assists in the treatment planning process by
communicating esthetic problems to the patient, laboratory personnel, and other specialists.

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

STATEMENT OF PROBLEM: Fracture of acrylic resin prosthetic teeth from acrylic resin denture
bases can be a problem for some patients. The optimal combination of acrylic resin denture tooth,
denture base material, and processing method is not known.

Purpose. The objective of this study was to compare the tensile bond strengths of heat- and microwave-
polymerized acrylic resins among 4 types of acrylic resin denture teeth.

MATERIAL AND METHODS: Heat-polymerized (Lucitone 199) and microwave-polymerized (Acron

MC) acrylic resins were used. Four types of acrylic resin denture teeth (IPN, SLM, Vitapan, and SR-
Orthotyp-PE) were milled to a fixed diameter according to ADA specification no. 15. Ten specimens of
each tooth type were processed to each of the denture base materials according to the manufacturers'
instructions. Ten additional resin control specimens without teeth also were fabricated. Specimens were
thermocycled and tested for strength until fracture with a custom alignment device. Data were analyzed
with analysis of variance and Duncan's multiple range tests. A scanning electron microscope was used
to identify adhesive and cohesive failures within debonded specimens.

RESULTS: The mean force required to fracture the specimens ranged from 5.3 +/- 3.01 to 21.6 +/- 5.2
MPa for the microwave-polymerized base and 11.2 +/- 3.0 to 39.1 +/- 5.1 MPa for the heat-
polymerized base. The most common failure was cohesive within the denture tooth. With each base
material, Orthotyp and IPN teeth exhibited the highest bond strengths; SLM and Orthotyp bond
strengths were similar. In general, heat-polymerized groups failed cohesively within the denture base
resin or the tooth, and microwave-polymerized groups failed adhesively at either the ridge lap or
occlusal surface of the denture tooth.

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

36. Burns DR, Beck DA, Nelson SK.4 (2003) One goal of the American Academy of Fixed
Prosthodontics is regularly to publish comprehensive literature reviews on selected topics germane to
the discipline of fixed prosthodontics. The following report is the result of this goal and focuses on
provisional fixed prosthodontic treatment. Major subtopics include materials science and clinical
considerations involving natural teeth and dental implants. The interrelationship between provisional
and definitive fixed prosthodontic treatment is multifaceted and significant. Provisional therapy
involves numerous materials and techniques that require special knowledge and technical experience.
In this analysis, technical, clinical, and investigational articles are detailed and presented as a
comprehensive literature review to provide contemporary guidelines. Referenced publications were
found by conducting a Medline search and were limited to peer-reviewed, English-language articles
published from 1970 to the present. Materials used with provisional treatment are discussed in terms of
clinical selection and the influence of their physical properties on treatment outcome. Specific product
names and manufacturers are included in this report only when they are cited in the original referenced
publications.
37. Christensen GJ.8 (2003) Crowns and fixed prostheses are well-proven, accepted and routinely used
restorations. However, they occasionally come loose from tooth preparations. Many things can cause
these failures. In this article, I have discussed the following reasons for lack of adequate retention of
crowns and fixed prostheses: inadequate tooth preparation; too much trust in dentin bonding agents and
lack of adequate tooth buildup; tooth preparations that lack irregularities; improper selection of
cements; and lack of postoperative occlusal adjustment.

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

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

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

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

CONCLUSION: The results suggest that the In-Ceram Alumina short-span FPD is a viable prosthetic
alternative.

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

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

OBJECTIVE: To compare the aesthetic perception of different anterior visible occlusions in different
facial and dental views (frontal view, lower facial third view and dental view) by lay persons.

DESIGN: Cross-sectional survey, Lima, Peru, 2002.

SUBJECTS: The different views were rated by 91 randomly selected adult lay persons.

MAIN OUTCOME MEASUREMENT: Visual Analogue Scale (VAS) ratings of aesthetic perception of
the views.

RESULTS: Anterior visible occlusion, photographed subject and view (p<0.001) had a significant
effect on the aesthetic ratings. Also gender (p=0.001) and the interaction between gender and level of
education (p=0.046) had a significant effect over the aesthetic rating.

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

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

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

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

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

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

CONCLUSION

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

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

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