CLINICAL APPLICATION OF INNOVATIVE MEASUREMENT GAUGES FOR PREDICTABLE CORRECTION OF TOOTH SIZE/PROPORTION AND GINGIVAL ARCHITECTURE DISCREPANCIES Stephen J. Chu, DMD, MSD, CDT" Paul D. Fletcher, DDS? Adam J. Mieleszko, CDT° ental professionals have long beon guided by mathematical prinples when interpreting exthetic ‘propotions for their patients, whether it imolves teoth-toooth smile arangement or ceating proper tocth dimensions"! While many acknowledge that such principles are merely initiation points for a given smile design or reconstructive procedure, their very ‘existence appears to indicate practitioners’ desire for some predictable, objective, and reproducible means of achieving success in esthetic dentistry. The belief that the Golden Proportion unequiv- cally defines the standard by which anterior teeth sociate Profersar and Director Advanend CDE ram in Estetic Dentistry, Def of Perodontoloay implant Dents, New York University Cellege of Den- vate practice, New York, New York, USA. rote Clinica Professor, Department of Priadentoloay implant Dentistry, New York University College of Den- ‘try, New York, New York, USA, "Now York, New York, USA. Correspondence to: Dr Stephen J. Chu, NYU Collece of Dentisty, 150 East SBthStrect, Suite 3200, New York, NY 10185, USA. Email schuernel@aol com should be arranged has been perpetuated by au- thors such as Lombardi, Levin, and Rufenacht, who wrote intellectually stimulating articles and books, respectively, on esthetics and design.’**These con- cepts have been developed into usable tools such as the Golden Proportion Ruler (Bayview Dental Lab, Chesapeake, VA, USA) and the Golden Pro- portion waxing templates (Panadent, Grand Ter- race, CA, USA). The clinical reality, however, is thet intra-arch tooth arrangement guidelines such as the Golden Proportion are only applicable to a mi- narity segment of the patient population and pose some difficulty in their implementation:** In the 1990s, Preston demonstrated that the Golden Proportion existed in the relationship be- tween the maxilary central and lateral incisors in ony 17% of patients studied.* Studies by Ward also sug- gest that the Golden Proportion should not be con- sidered the intra-arch tooth proportion standard. Since 2001, Ward has done a significant amount of “perception-based” research comparing dental pro- fessionals’ and patients’ preferred choice of smile design based on the results of smiles created using the Recurring Esthetic Dental (RED) Proportion, the DT 2009)CHU ET AL portion: Fig 1, The most pleasing width-length ratio falls between 75% and 80%. (Courtesy of Dr Gerard Chiche.) Golden Proportion, or naturally occurring tooth-to- tooth width proportion relationships previously re ported in the North American population." His, findings suggest that tion of the Golden Proportion should be reconsidered, as it was found to be the least pleasing and least accepted among dentists and patients in Conversely, tooth size, composed of width and length dimen and can be considered one of the building blacks of the smile, Tooth size is directly related to tooth proportion, which is expressed as tooth width vided by tooth length times 100. An analogy can be made to the edentulous patient, where the fist step is selection of the correct mold or tooth size harmonious within the dental arch, prior to tooth arrangement. This task cannot be accomplished successfully if the teeth selected are inadequate horizontally and/or vertically in dimension, The same applies to the dentate patient, in whom the dentition often presents with variations in tooth size that ultimately negatively affect not only tooth pro: ited States." ions, is a critical element in esthetics portion but also the gingival architecture. Tooth Proportion values above 85% lend to the appear- ance of excessively short and square teeth, while those below 65%, similar to mandibular anterior teeth, appear too lang and rectangular (Fig 1) SIZE MATTERS Tooth proportion values for anatomic teeth vary from 73% to 78%, while clinical crowns are slightly higher, ranging from 76% to 86%." Combining these studies on tooth proportion values gives an average of approximately 80%. In addition, mean values for tooth dimensions cannot be used rou tinely or predictably, since they apply only about third of the time. Tooth size variation is the rule (~66%4), not the exception; however, tooth propor: tion remains constant. Nevertheless, 80% of the population will reside at £0.5 mm of these mean values. There is also a correlation between the width of the central incisor, lateral incisor, and cay nine teeth, invariably, tho widths of the lateral in cisor and canine teeth are predicated on the cen: tral incisor being 2 mm and 1 mm less in width, respectively, for average to large teeth. For smaller teeth, the relationship is constant but the lateral in Cisor is 1.5 mm less in width, with the canine re- maining 11mm less than the central. Tooth shape is also a critical factor in the per ception of tooth width, especially with multiple- tooth restorations; however, changes in form and contour are limited when addressing tooth length discrepancies.Measurement Gauges for Correction of Tooth Size/Proportion and Gingival Architecture Figs 2a and 2b A malformed dentition is often the result of hereditary predisposition. Note the macrodontia (maxi laty right central incisor, which wil ultimately affect the patient's esthetic and occlusal outcome, Figs 3a and 36 Microdontia (maxillary laft central inciscr) negatively afects the dentofacial appearance of the smile, The tooth’s ciminutive size impacts the occlusal scheme, which in this case is a Class 3 melocclusion. Figs 4a and 4b Restorations created without definitive proportion guidelines (ie, those determined by “eye balling") can result in inadequate esthetic and occlusal outcomes. FACTORS AFFECTING TOOTH SIZE In daily practice, clinicians observe teeth whose sizes are abnormal relative to accepted clinical Crown with and height values (Figs 2 and 3). Etiolo- gles that contribute to malformed or incomplete entitions include hereditary (congenital) conditions such as missing lateral incisors or dentinogeneis im- perfecta, and partial odontia with or without trans: position of teeth. Thore are also certain disease states that can lead to compromised tooth struct ture, These include gastroesophageal refiux dis- ‘ease, which erodes incisal edges, resulting in exces sive gingival display as well as compensatory erup- tion of opposing dentition; bruxism, which causes short teeth dus to incisal attrition; and aging, which causes long teeth due to gingival recession. No matter what the cause of tooth-size dispari- ties, when it comes time to restore these teeth, the application of nonstandard proportions, io, “eye- balling,” can yiold teeth that are unnatural in size and fil to achieve the esthetic expectations of either dental pationt or professional (Figs 4a and 4b). A more definitive, less subjective approach to obtain- ing ideal restoration parameters is required to obtain nical success in the final treatment outcome. (ant 2009CHU ET AL [Fy EE, bE Figs Sa to Sc Accurate determination of ideal tooth length and width ratios is facilitated with the Proportion Gauge (Hu-Friedy, Chicago, IL, USA). The width is indicated in equidistant increments of color, each with a vertical mark in the corresponding color indicating proportional height. Thus, a cen- tral incisor with 2 “red width of 8.5 mm wil be in proper proportion if ts BEGIN WITH THE END IN MIND Whether an esthetic restorative case involves a few anterior teeth or encompasses full-mouth recon- struction, the clinician should be familiar with dis ccrepancies in tooth size at the initial ciagnosis and. treatment-planning stages. To eliminate some of the subjectivity associated with esthetic treatment planning and restorative care, new clinical tools have been developed to accurately and easily ob- ‘ain intial tooth size (length and wicth), and also assist with determining new and proper tooth pro- portions of each individual restoration.” Through the use of such instrumentation, the clinician is able to apply esthetic and anatomic tooth proportions directly to a patient chairside or indirectly in the dental laboratory during projected treatment planning, as well as objectively deter- mine the intended treatment outcome.’“” One of, the aforementioned tools features an established rest position at the incisal edge; when a tooth is seated accordinaly, the practitioner can accurately evaluate its ideal length and width ratios (Figs Sa and Sb). The width is indicated in equidistant in- height i also is the "red" zone (ie, 11 mm). Fig 6 The Crown Lengthening Gauge (Hu-Fried) has a biologic perio- gauge LPG) tip designed to si Of the Biologic crown (e, bone crest to the incisal adge) during surgical crown-lengthening procedures. juRaneously measure the midfacial length crements of color commensurate with measure- ment values, each with vertical mark in corre- sponding color reflective of proportional height Fig 50. Consequently tooth size and proportion dictate esthetic crown lengthening because teeth often are too short due to incisaledge changes sec ondary to parafunction. Should crown lengthening be necessary to achieve an esthetic result, the 1- mm increments marked on the vertical axis of the crown-length tool yield predictable requirements for the increased vertical height and/or interproxi- mal height of bone (Fig 6). CASE PRESENTATION In the case presentation that follows (Figs 7 to 28), the Aesthetic Gauges (Hu-Friedy, Chicago, IL, USA) are demonstrated in the treatment planning and restoration of a 39-year-old man who presented for esthetic restorative care of fractured anterior teeth and enhancement of the existing dentition, Acci- ‘QT 2009Measurement Gauges for Correction of Tooth Size/Proportion and Gingival Architecture Figs 7a and 7b Trauma to the patient’ maxillary right central and lateral incisors resulted in fracture ofthe in- cisal edges. He was also unhappy with the restorative margin of the maxillary left cantralful-coverage restors- tion, Figs 8a and 8b The patient also presented with excessive overbite relationship of the anterior dentition and tooth-width dental trauma resulted in incisal fracture to the maxillary right central and lateral incisors, and the patient was also unhappy with the left central in- cisor, a previous full-crown restoration with a ging val margin that had become too short due to the patient's gingival recession. Diastemata between the central incisors and the right lateral incisor and canine were also an esthetic issue requiring corec- tive measures. The patient presented with a large ;pancies (diastemata] between the central incisors and left lateral incisor and canine. ‘tooth size and proportion, which is not uncommon in males, Esthetically and functionally, increasing ‘the incisal length was not an option. Therefore, the treatment plan included crown lengthening on all four maxillary incisors to achieve the proper tooth length relative to the corrected tooth width of the central incisors, which would effectively eliminate ‘the diastemata as wel nT 2009)CHU ET AL Fig 9a. The T-bar tip of the Proportion Gauge indicatos the tooth length is not in corroct proportion to tho width, With an increase in tooth width one colored band unit beyond the outer red borders on the horizontal arm (dotted lines), the proportionally (78%) correct tooth length is half the distance on the vertical yellow band, Fig 9b Waxup with correction of the width discrepancy only Fig 9¢ Waxup with conection of the length proportionally guided by the gauge. Figs 10a to 10¢ Preoperative stone cast, width correction, and proportional length conection, respectively show the esthetic outcome of the waxup. Gingival levels and zerith pesttions willbe corracted withthe por- ‘edonal crown lenatening procedure Figs 11a and 11b Designed to piece the supracrestal gingival fibers, a Sounding Gauge is used to deter- mine the level ofthe bone crest midacil osseous cies) prior to flep reflection. The average midacial den- tagingwval complex 3 mm) is noted. The curved tip of the Sounding Gauge is 1 mm wide and designed to fel- lowr the tooth and cementoenamel junction anatomic contauirs ‘ODT 200Measurement Gauges for Correction of Tooth Size/Proportion and Gingival Architecture Figs 12a and 12b bar tip of the Proportion Gauge is used to assess the correct length of the tooth relative to the new width, and intentional biologic width violation is performed via ginglvectomy. After gingivectomy, the Sounding Gauge is placed to assess the bone crest location, which is now about 1 mm (inadequate fer bi- logic and esthetic health Fig 13a Provisional restorations are inserted, noting the adverse tissue reaction involving the central incisors ‘allowing intentional biologic wieth violation through gingivectomy. Fig 13b T-bar is used to verify the accurate proportions of the width and length. Fig 13c BLPG tip is used to measure the mifacial length of the provisional and biologic crown simultane ously at +3 mm Figs 14a and 14 DLGP tp of the Crown Lensthening Gauge i used for precise visual verication thatthe proper amount and shape of osseous resection & perormed. Tho comrescencing later measurement was Used consistent withthe tooth size and proportion analysis, which Gictates crown lengtheningm ODT 5b Figs 1Sa and 15b Staight po- odontal probe (is less accu fate in meoeuring the curvatur> fof the exposed root surface ‘ter osseous recontouring ‘compared to the curved Sounding Gauge fb). The Sounding Gauge found 4 mm (os 3 ren midlacialsuleus, pro- viding an addtional 1-mam sul- cus depth to menage the restorative margin location sub- ginghally. Fig 16a Papillatip of the Crown Lengthening Gauge is Used to assess the proper Pilla location (dotted line) from the gingival zanith on Cisal edge position (40% and 60% incisogingival tooth lenath, respectvely).*” Figs 16b and 16¢ Once the flap is veflacted, the surgeon mmuist be able to visualize the clinical soft tssue position of ‘the papilla as well asthe inter- dental bone crest position Using the 3- to 5-mm rule.” Fig 16 Final nterdental la ap suited an ite postion serted posturgealy ting the papila tip ofthe Grown Lengthening GaugeMeasurement Gauges f Correction of Tooth Size/Praportion and Gingival Architecture 173 [7b Figs 17a and 17b After adequate soft tissue healing (3 months), the provi sional restorations were replaced. The: correction of the proper tooth sie and gingival architecture is now evident. Fig 182 Once the gingival tissues had healed, the teeth wiere prepared in a conservative manner for ceramic ve- vers (ght conta and ight ane et lateral incisors) and no-prep veneer left canine, mesiofacial Fig 18 Impressions were made. Fig 18¢ Stone and refractory costs were fabricated in the lab for restora- tion construction. Figs 19a to 19¢ To ensure proper shed matching and communication to the laboratory technician, numerous photographs of bath anterior arches were taken and assessed, including fll- face, close-up of natural and protracted preoperative smile and teeth, as well as the "stump" preparation shade,CHU ET AL (238 236 Figs 20a to 20¢ Full-crown restoration primary "base" shade is colorized to the “stump” shade of the ve. rReored natural teeth. In addltion, the shape of the base shade ceramic bulldup mimics that of the veneer preparations. Fig 21a Proper "base-stump” shade was confirmed. Figs 21b and 21¢ Silicone putty matrix was used to assess the proper facial, proximal, and incisal fabrication af the full con “stump” relive to the veneer preperation, Subsequent veneting ceramic shoud be equal fr all preparations, Figs 22a to 22c Further shade matching and characterization details were achieved with the application of dentin, enamel, mammelon, incisal, and special effect porcelain powders. Figs 23a and 23b Proportion Gauge wes used in laboratory fabrication and size verification of the restora tions. The final tooth sizo was larger than average, at 9.5 mm in width and 12 mm in lengthFig 24a Final ceramic restorations are devested and ‘contacts ftted on the eoid die cast Figs 24b and 24¢ Note the light transmission qualities of the all- ceramic synthetic porcelain material (Venus Porcelain, Heracus Kulzer, South Bend, IN, USA) for the veneer (left lateral incisor) and no-prep ve- ner (left canine, mesiofacial). The venzer restorations were prepared in the laboratory for resin cement ‘iorVbonding via 90 secands hy. droflueric acid etching, Figs 25a and 25b Finished all ceramic (ztconia-based) restoration (eft central incisor) and feldspathic ‘ceramic veneers (right incisors and left lateral and canine) are Wied in or the stone cast and clinically folowing ‘cementation. i24bCHU ET AL Figs 26a to 26¢ Tiy-in also demonstrated that diastersta have been eliminated, and the width and length of the restorations are naw in Visual harmony within the dental arch Figs 27a to 27¢ Final tooth size and propor tion ofthe defntve restorations were veried inthe laboratory using the -Bzt tp ofthe Pro- orton Gauge. The corect clinical crown Fength empleying esthotc periodontal srown longthening was created vith the aid of tho, BLPG tip of the Crown Lengthening Gauge and popill location relative tothe corrected tooth Fength from the incisal edge position 74] anT 2009Measurement Gauges for Correction of Tooth Size/Proportion and Gingival Architecture Figs 28a and 28b Extroorel dentofacial views of the es- thetic restorative outcome, which demonstrates harmo- rious correction of tooth proportion and gingival ar- Chitecture discrepancies, ‘commensurate with 2 pleas- ing smile. ACKNOWLEDGMENTS REFERENCES “The author isthe inventor af Chu’ Aesthetic Gauges and 1, Lombardi RE. The principles of veval perception and their serves a8 2 consultant in the development of esthetic insta Clinical appliation to denture esthetics. J Prosthet Dent ont forthe HusFiedy Co, 1973,29-358-382 2, Levin El. Dental esthetics and the golden proportion. 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