AESTHETIC DESIGN PRESERVATION IN ... Design...AESTHETIC DESIGN PRESERVATION IN MULTIDISCIPLINARY THERAPY: PHILOSOPHY AND CLINICAL EXECUTION Ernesto A. Lee, DMD* Sang K. Jun, CDT†

AESTHETIC DESIGN PRESERVATION

IN MULTIDISCIPLINARY THERAPY:PHILOSOPHY AND CLINICAL EXECUTION

Ernesto A. Lee, DMD*Sang K. Jun, CDT†

Pract Proced Aesthet Dent 2002;14(7):561-569 561

Complex perio-prosthetic cases that require multidisciplinary therapy often result incompromised aesthetics. Traditional treatment planning philosophies, as well as exist-ing interdisciplinary relational patterns, do not promote the achievement of predictableaesthetic results. Implementation of a restorative-driven approach requires the develop-ment of an aesthetic blueprint that will serve as a guide through treatment. Thisarticle illustrates the clinical techniques and sequence for an outcome-basedprotocol that enhances therapeutic cohesiveness and ensures the sequential transferof design objectives for the preservation of aesthetics in multidisciplinary therapy.

Key Words: multidisciplinary, prosthetic, template, aesthetic

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*Adjunct Professor, Postdoctoral Periodontal Prosthesis, University of Pennsylvania School ofDental Medicine, Philadelphia, Pennsylvania; Adjunct Professor, Advanced Esthetic DentistryProgram, New York University College of Dentistry, New York, New York; private practice,Bryn Mawr, Pennsylvania.

†Laboratory technician, Bay Dental Laboratories, Monterey, California.

Ernesto A. Lee, DMD, 976 Railroad Avenue, Ste 200, Bryn Mawr, PA 19010Tel: (610) 525-1200 • Fax: (610) 525-1956 • E-mail: [email protected]

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Predictable aesthetic outcomes resulting from multidis-ciplinary treatment approaches have traditionally rep-

resented elusive goals. This may be partially due to thelevel of complexity that is associated with theseclinical scenarios. In addition, it may be a result of theinadequate interaction between the specialists involved(Figure 1).1 The role of the patient’s perception in deter-mining acceptable treatment outcomes also constitutes apotential obstacle in achieving aesthetic success.2-4

Patients who require multidisciplinary therapy mayfall into two different categories. There are situationswhere conformance with the standard of care demandsthe inclusion of several dental specialties within the ther-apeutic team (Figures 2 through 4). Alternatively, thereare scenarios where the patient may be treated in a satis-factory manner with a compromised restorative solution,and adjunctive procedures are, nevertheless, incorpo-rated to enhance the definitive aesthetic result.

This article will describe an aesthetic-driven sequenceand treatment rationale that may promote increased cohe-siveness of the clinical team involved in rendering multi-disciplinary therapy. The treatment philosophy andtechniques required to ensure the accurate transfer of theinitial restorative design through all adjunctive proceduresand various phases of clinical execution are illustratedand discussed herein.

Aesthetic-Driven Multidisciplinary TherapyAesthetic success can be reliably predicted only throughthe development of a systematic treatment approach thatincludes the comprehensive integration of a previouslydefined restorative outcome. This concept is not unlikethe generally accepted restoration-driven approach toimplant therapy, which includes the development of a

prosthetic blueprint early in therapy.5,6 Aesthetic-drivenmultidisciplinary therapy requires a philosophical depar-ture from generally accepted concepts regarding thetreatment planning and sequence of adjunctive proce-dures. Furthermore, a reevaluation of the currently utilizeddefinitions and the relationship between form and func-tion as it relates to the masticatory system is appropriatevis-à-vis the prevailing clinical ethos to subordinate formto functional requirements.

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Practical Procedures & AESTHETIC DENTISTRY

Figure 1. A 36-year-old female patient presented forprosthetic evaluation following completion of periodontaland orthodontic therapy. Note revealing smile line.

Figure 2. Periodontal surgery was previouslyperformed at age 25, and the maxillary ante-rior teeth were splinted with intracoronal wireligatures.

Figure 3. Significant attachment loss was evidentin the posterior regions, along with depressiblemaxillary molars. Recent periodontal activitywas refractory in nature.

Figure 4. Maxillary anterior teeth exhibitedmoderate to advanced attachment loss anddegree 2 mobility. The clinical scenario wassuggestive of rapidly progressive periodontitis.


The role of the human dentition has evolved in con-junction with the progress of mankind. In primitive soci-eties, the stomatognathic system primarily fulfilledalimentary needs, and its functional integrity would oftenbe associated with the individual’s survival.7 Any con-temporary definition of the functional role of the humandentition in modern society, however, cannot be limitedsolely to masticatory activity. A healthy self-perception ofaesthetic adequacy carries emotional, psychological,

and social benefits. Since the appearance of the teethconstitutes a major component of the facial composition,the aesthetic aspects of the dentition must be identifiedwithin a functional context. It is appropriate in this regardthat clinicians view their treatment goals as extendingbeyond the compartmentalization of the oral cavity, focus-ing instead on the benefit of the patient as a whole.4

Does Form Follow Function?The postulate stating that “form follows function” was ini-tially utilized in a biologic context by Jean-Baptiste deLamarck, an 18th century French zoologist, as part ofhis theory of natural adaptation.8 Lamarck deducted thatanatomical forms developed as a response to environ-mental demands and that these organic adaptations even-tually became part of the genetic pool and weretransmitted to offspring of the species. A typical examplewas the giraffe, which was thought to have developedits elongated neck and body shape as an adaptation tomore effectively access its food supply. Even though thistheory eventually fell out of favor largely as a result of theacceptance of Darwin’s theory of evolution by the scien-tific community, the form follows function postulate con-tinued to be utilized in many of the biological sciences.9

Unfortunately, it is this teliologic belief that providesthe framework for the philosophical acceptance of aes-thetic compromise, when in fact there is no scientific ortechnical basis to support its raison d’être or applicability— at least within the context of restorative dentistry. In otherwords, if form does indeed follow function in restorativedentistry, then aesthetics are secondary to biological andbiomechanical considerations. Conversely, if aestheticacceptance is one of the requirements that must be fulfilled in order to achieve success in restorative dentistry,

Figure 8. Appearance of healed soft tissues following flapreposition. Tooth position was modified to comply withGolden Proportion guidelines.

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Figure 5. Interproximal ameloplasty and ortho-dontic therapy were instituted to erupt the maxil-lary anterior teeth and consolidate gingivalembrasure spaces.

Figure 6. Once orthodontic objectives wereachieved, a diagnostic template was developedto preview the aesthetic proposal.

Figure 7. The surgical guide outlined the pro-jected restorative margins to ensure adequatebiologic width space and continuity of theaesthetic blueprint during bone contouring.


biological and biomechanical limitations must be figuredinto the equation during the development of the aestheticproposal. Indeed, it may be more appropriate to statethat new algorithms must be developed to better articu-late the relationship between form and function.

Clinically Relevant Aesthetic BlueprintsThe successful integration of aesthetics and functionalitydoes not emerge by chance, but as a result of the metic-ulous development of clearly defined anatomical param-eters and their subsequent incorporation into the designof the prosthesis.10-12 This process requires an initial visu-alization of the desired end result, followed by a proto-col that allows the progression from the realm of theabstract to concrete and material clinical objectives.

The establishment of the aesthetic scheme must beconsidered an integral component of the diagnosticphase. Once aesthetic objectives are defined, adjunc-tive treatment considerations are developed to supportthe desired restorative outcome. This approach advancesa departure from traditional treatment planning sequencesin that it organizes all adjunctive therapy in subordina-tion to the desired aesthetic result, except for control ofactive disease processes and emergency procedures.12

Complex treatment planning approaches are oftennecessary in situations where multidisciplinary therapy isindicated. The recruitment of specialists per se does not,however, have an additive effect on the desired aestheticoutcome. The preservation of aesthetics through multi-disciplinary therapy requires the development of the clini-cal team into a cohesive therapeutic network supported bythe establishment of a clinically relevant aesthetic template.

Development of the aesthetic proposal and subse-quent blueprint will help to identify specific therapeuticobjectives for each specialist involved in the multidisci-plinary team and the laboratory technician as well.Individual specialty procedures cannot be subject to thewhim of each clinician’s perspective, but rather requiresubordination to the aesthetic scheme. This demands thatspecific guidance be provided for the specialist in termsof clinical objectives. The aesthetic blueprint additionallyneeds to fulfill requirements of clinical relevancy in thatit must easily convey the parameters within which eachspecialty procedure must be performed; all this presentedin a practical and accessible format. Surgical guidesand therapeutic templates are thus developed, provid-ing a mechanism for the specialists to intraoperativelyverify compliance with previously established perfor-mance parameters.

This process is often initiated with the developmentof a diagnostic waxup. The diagnostic waxup must bedeveloped to reflect any contributory adjunctive proce-dures that may be contemplated as part of the multidis-ciplinary treatment plan, with the purpose of establishingan aesthetic restorative design in the wax stage that will

Figure 10. Completed preparations exhibited adequateparallelism to allow fabrication of the planned metal-ceramic splints for control of secondary occlusal trauma.

Figure 11. Gingival margin levels were verified andrevised using the diagnostic template for sequentialtransfer of the initial aesthetic design.

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Figure 9. Tooth reduction was initiated from the ultimateincisal edge position. Preparation design followed theanticipated contours of the definitive restorations.


closely resemble the desired definitive result.12 The uti-lization of techniques that allow the intraoral testing ofthe restorative proposal constitutes the most valuableresource in the assignment of clinical relevancy to theaesthetic blueprint. Whether it is through the use of directtrial composite veneers, removable aesthetic templates,

or provisional restorations; aesthetic treatment objectivescan be clinically refined and accurately represented tothe patient only by trial in an in vivo environment.12

Orthodontic ConsiderationsOrthodontic treatment is often an integral component ofmultidisciplinary therapy, frequently enhancing the aes-thetics of the final restoration. A distinction must be made,however, between such instances where orthodonticmovement is primarily utilized to facilitate the completionof a prosthesis without aesthetic compromise and clini-cal scenarios where complex functional and pathologicinvolvement require the use of orthodontic therapy inorder to comply with the standard of care.

The beneficial effects of orthodontics in multidisci-plinary therapy can only be optimized provided that thetooth movement is designed to support a preestablishedaesthetic scheme. This methodology is advantageous inthat it identifies an endpoint reference position to whichthe teeth must be moved. The orthodontic blueprint mustbe aesthetically generated, with anterior tooth displayconsiderations constituting a significant determinant ofultimate tooth position. Exclusive reliance on cephalo-metric analysis or occlusal relationships based on Angle’sclassification may not be an adequate approach ininstances that exhibit a lack of coincidence with optimaldentolabial aesthetics.1,13

Although orthodontic therapy is primarily utilized toimprove tooth position and interarch relationships, itseffects on osseous architecture and soft tissue remodelingmay be advantageously applied in the treatment of perio-dontally compromised dentitions (Figures 5 through 8).To this effect, Ingber reported on the use of orthodonticforced eruption for the treatment of periodontal verticaldefects.14 The attendant bone remodeling results in afavorable modification of the osseous defect while improv-ing the alveolar bone architecture as well. In addition,the coronal migration of the attachment apparatus willbe accompanied by gingival tissue changes that resultin the eversion of sulcular epithelium and a concomitantdecrease in probing depths. This application is a commonfeature in the management of periodontal/prosthetic cases,where it may be utilized in conjunction with the aestheticblueprint concept to create powerful therapeutic synergies.

Orthodontically induced bone remodeling may alsobe utilized for the development of future implant sites.15

When appropriately integrated into the overall treatmentscheme, this technique can provide one of the most pre-dictable sources for vertical bone augmentation, offering

Figure 13. An index patterned after the optimizedprovisional was used to verify that tooth reduction wasconsistent with preestablished aesthetic objectives.

Figure 14. Maxillary abutments following retraction cordplacement. Note adequate gingival health, atraumaticplacement technique, and resultant moisture control.

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Figure 12. Once the provisional prosthesis was function-ally and aesthetically optimized, it became a blueprintfor the completion of the definitive restoration.


additional advantages with regard to time efficiency,while remaining a nonsurgical approach as well.

Tarnow et al studied the relationship between theproximal contact and the underlying osseous crest andits effect on the presence or absence of a gingivalpapilla.16 Their findings demonstrate that papillae werepresent 100% of the time whenever the distance betweenthe proximal contact and the osseous crest did not exceed5 mm. There are currently no surgical approaches to pre-dictably regenerate missing gingival papillae. With acombination of interproximal ameloplasty and subsequentorthodontic space consolidation, however, the proximalcontact to osseous crest relationship can be favorablymodified to promote formation of a gingival papilla(Figures 5 and 6). Thus, orthodontic therapy providesthe only available means of predictably regeneratingdeficient gingival papillae, and as such it constitutes aninvaluable technique in the aesthetic armamentarium.

Periodontal ConsiderationsComplex cases that require multidisciplinary therapy oftenincorporate significant periodontal etiologic factors.Advanced loss of attachment, secondary occlusal trauma,and the presence of parafunctional habits are commonlypresent in periodontal/prosthetic cases, along with migra-tion of teeth, posterior bite collapse, and loss of occlusalvertical dimension.17 Preserving aesthetics through thedelivery of periodontal therapy under these circumstancesdiffers significantly from those scenarios where perio-dontal procedures are performed primarily for aestheticpurposes, and its proper execution requires an altogetherdifferent mindset and skill level as well.

Periodontal etiologic factors must be carefully ascer-tained, particularly in patients who exhibit a pattern ofattachment loss and clinical characteristics that deviatefrom those usually associated with adult periodontitis(Figures 3 and 4). Clinical profiles suggestive of condi-tions such as rapidly progressive periodontitis are of concern due to their resistance to conventional perio-dontal therapy as well as their refractory nature. Thesepatients require a keen evaluation that must include bacterial sampling and culture, followed by adjunctiveantibiotic management.18-20

Planned periodontal procedures should be performedpreoperatively on study models. Diagnostic templates orwaxups will be subsequently developed reflecting theanticipated postsurgical gingival margin levels (Figure 6).In any situation where a revision of the gingival marginsis being considered, bone sounding is compulsory to

identify the level of the alveolar crest and ascertain theneed for osseous surgery.21 Following bone sounding,several scenarios are possible. Ideally, there may be suf-ficient tissue present coronal to the osseous crest to allowfor a gingivectomy or gingivoplasty procedure that willestablish the desired gingival margin position without vio-lating the biologic width.22 Another possibility is the pres-ence of sufficient gingival tissue to allow the repositionof the gingival margin without exposing the osseous crestbut nevertheless impinging on the biologic width. Thelatter situation allows the restorative dentist to establishthe optimal gingival margin levels with the provisionalrestoration, which is subsequently utilized by the perio-dontist as a surgical guide for contouring the osseouscrest to reestablish the biologic width space without alter-ing the previously determined gingival margin levels.23,24

Bone sounding may alternatively reveal a situationwhere repositioning the gingival margin to the desired post-operative level will not be feasible without exposing theosseous crest. This scenario precludes any gingival revi-sion prior to surgical bone recontouring. In these cases,

Figure 16. View of the master model demonstrated toothpreparation details. Molar furcation anatomy was modifiedfollowing perio-prosthetic guidelines.

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Figure 15. A full-arch impression was taken to accuratelycapture the 12 consecutive abutments. A one-step,dual-viscosity polyether technique was used.


a surgical guide derived from the aesthetic blueprint mustbe provided to the periodontist to serve as a templateduring surgery. Following flap reflection, the surgical guidewill aid the clinician in establishing a constant relation-ship between the anticipated clinical crown margin andthe osseous crest levels (Figure 7). The periodontist is alsoinstructed to reposition the flaps rather than apically posi-tion them, therefore preserving sufficient amounts ofsupracrestal tissue to allow for the anticipated revisions tothe gingival margin levels once healing from the osseoussurgery has been completed (Figures 9 through 11).25,26

Provisional RestorationsThe completed laboratory waxup, reflecting plannedadjunctive procedures, is utilized as a basis for the fab-rication of a provisional prosthesis. The outcome-basedrestorative rationale dictates that the sequence of ther-apy be altered to incorporate the provisional prosthesisinto the diagnostic phase of therapy whenever possi-ble. Since the aesthetic outcome is preestablished in thewaxup and subsequently programmed into the design

of the provisional prosthesis, the latter may be utilizedas a guide during adjunctive treatment procedures. Multi-disciplinary cases requiring significant orthodontic ther-apy may present an exception, though, since it may notbe practical to predict extensive changes in tooth posi-tion with sufficient accuracy to warrant developing theprovisional prosthesis directly from the diagnostic waxup.

Following intraoral placement, the provisional pros-thesis is gradually modified until all the objectives requiredin the final restoration have been achieved.27 Once thisis accomplished, the functional and aesthetic outcomehas been defined in the finalized provisional prosthesis,creating a template from which the design of the defin-itive restoration will be generated (Figure 12).

Restorative ConsiderationsMeasures must be taken to ensure that the definitiverestoration replicates the anatomic details developed inthe finalized provisional restoration.28 This process is ini-tiated intraorally with the use of silicone indexes of theprovisional prosthesis to verify adequate tooth reduction(Figure 13). To this effect, it is important to note that toothpreparation must follow outcome-based guidelines, wherethe appropriate amount of reduction is determined basedon the outline form desired in the definitive prosthesis. Inother words, although 1.5 mm to 2 mm of tooth reduc-tion will provide sufficient space for metal-ceramics, thisspace should not be measured from the unprepared toothsurfaces but from the projected contour of the final restora-tion (Figures 9 and 10).

Once space requirements are satisfied, the procure-ment of accurate definitive impressions is quintessentialto the fabrication of indirect restorations. Adequate perio-dontal health is a prerequisite to maintain predictablepostimpression gingival margins. The presence of ulcer-ated sulcular epithelium as well as an inflammatory infiltrate in the connective tissue attachment promotesextravasation and increases sulcular fluid flow, both ofwhich may impede the achievement of adequate hemo-stasis and moisture control.29 Additionally, the responseof inflamed tissues to the impression procedure is vari-able and will decrease the predictability of the ultimategingival margin levels.

The double-cord elastomeric impression techniquehas proven extremely reliable.30 Atraumatic cord place-ment is mandatory if soft tissue marginal integrity is to bemaintained. Proper technique will limit cord placementto the gingival sulcus and the junctional epithelium. Inthe presence of adequate gingival health, displacement

Figure 18. Metal framework design was verified with theprovisional restoration index to ensure aesthetic blueprintpreservation through the fabrication stage.

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Figure 17. The waxup was developed to full contour andcolor to allow an intraoral preview of minute characteriza-tion details and shade mapping schemes.


of the hemidesmosomal epithelial attachment will notelicit bleeding, and extravasation will occur only if traumais introduced at the connective tissue attachment level(Figures 14 through 16).31

Finally, a category of restoration congruent withthe previously established functional and aesthetic objec-tives must be selected. Complex periodontal prostheticcases with advanced periodontal involvement includingsecondary occlusal trauma require splinting, and this ismost predictably accomplished with the use of porcelain-fused-to-metal prostheses (Figures 17 through 19).17

Laboratory ConsiderationsPrecise intraoral replication and occlusal articulation arecritical requirements to initiate the laboratory phase.Nevertheless, interocclusal relationships inclusive of tra-ditional face-bow transfer techniques do not constitutesufficient information per se for the reliable visualizationof dentofacial aesthetic parameters in an indirect environ-ment, such as a remotely located laboratory precludingpatient/technician contact.32 It is imperative that an aes-thetically oriented face-bow technique be utilized, allow-ing for the transfer of the relationship between the occlusalplane and the horizontal plane of reference. Contrary topopular belief, the bipupillary line is of little value to thetechnician unless it is parallel to the horizontal plane.Additionally, photographic documentation displaying thepatient’s facial features is essential to develop a harmo-nious dentofacial composition.33

Aesthetically demanding circumstances may bemanaged through the use of a full-shade waxup tech-nique.34 The waxup is developed on a refractory modelto full contour and color characteristics. These will notonly include a general shade but also color mappingschemes, as well as individual variables taking into con-sideration the patient’s age and physiognomic charac-teristics (Figure 17).

The wax copings possess sufficient strength andretention to allow complete seating over the prepared teeth,therefore facilitating intraoral testing. Highly specific aes-thetic details (eg, enamel craze lines, incisal halos, decal-cification areas, and surface textural patterns) may beincorporated in the wax. This technique allows the patientand clinician to prospectively evaluate the in vivo appear-ance of the proposed restorations and effect any appro-priate modifications. More importantly, the ceramist cansubsequently fabricate definitive restorations that accu-rately replicate the full-shade waxup, including minutecharacterization details (Figures 20 and 21).35,36

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Figure 21. Postoperative appearance of the rehabilitatedsmile. Note the harmonious dentolabial compositionand gingival display.

Figure 20. Facial view of the restored maxillary anteriorsegment 1 week postcementation. Note gingival marginsymmetry and regenerated papillae.

ConclusionThe preservation of aesthetic objectives in the treatmentof functionally compromised dentitions that require mul-tidisciplinary therapy represents a considerable clinicalchallenge. Not only are there more demands of asso-ciated skill levels, but a different mindset is required toallow a conceptual departure from traditional therapeu-tic paradigms. It is important to differentiate between

Figure 19. Appearance of the full-arch metal-ceramicrestoration, designed in three splinted segments forcontrol of tooth mobility patterns.


10. Levin EI. Dental esthetics and the Golden Proportion. J ProsthetDent 1978;40(3):244-252.

11. Lombardi RE. The principles of visual perception and their clin-ical application to denture esthetics. J Prosthet Dent 1973;29(4):358-382.

12. Lee EA, Jun SK. Achieving aesthetic excellence through an out-come-based restorative treatment rationale. Pract PeriodontAesthet Dent 2000;12(7):641-648.

13. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosisand treatment planning - Part I. Am J Orthod Dentofac Orthop1993;103(4):299-312.

14. Ingber JS. Forced eruption. Part I. A method of treating isolatedone and two wall infrabony osseous defects — Rationale andcase report. J Periodontol 1974;45(4):199-206.

15. Salama H, Salama MA. The role of orthodontic extrusive remod-eling in the enhancement of soft and hard tissue profiles priorto implant placement: A systematic approach to the manage-ment of extraction site defects. Int J Periodont Rest Dent 1993;13(4):312-333.

16. Tarnow DP, Magner AW, Fletcher P. The effect of the distancefrom the contact point to the crest of bone on the presence orabsence of the interproximal dental papilla. J Periodontol1992;63(12):995-996.

17. Amsterdam M. Periodontal prosthesis. Twenty-five years in ret-rospect. Alpha Omegan 1974;67(3):8-52.

18. The American Academy of Periodontology. Proceedings of theWorld Workshop in Clinical Periodontics. Chicago, IL: TheAmerican Academy of Periodontology, 1989.

19. Genco RJ. Classification and Clinical and Radiographic Featuresof Periodontal Disease. In: Contemporary Periodontics. St. Louis,MO: The CV Mosby Company, 1990.

20. Slots J, Bragd L, Wikstrom A, Dahlen G. The occurrence ofActinobacillus actinomycetemcomitans, Bacteroides gingivalis,and Bacteroides intermedius in destructive periodontal diseasein adults. J Clin Periodontol 1986;13:570-577.

21. Studer S, Zellweger U, Scharer P. The aesthetic guidelines ofthe mucogingival complex for fixed prosthodontics. PractPeriodont Aesthet Dent 1996;8(4):333-341.

22. Ingber JS, Rose LF, Coslet JG. The “biologic width” — A con-cept in periodontics and restorative dentistry. Alpha Omegan1977;70(3):62-65.

23. Kois JC. Altering gingival levels: The restorative connection. Part I:Biologic variables. J Esthet Dent 1994;6(1):3-9.

24. Kois JC. The restorative-periodontal interface: Biological para-meters. Periodontol 2000 1996;11:29-38.

25. Allen P. Use of mucogingival surgical procedures to enhanceesthetics. Dent Clin North Am 1988;32(2):307.

26. Lie T. Periodontal surgery for the maxillary anterior area. Int JPeriodont Rest Dent 1992;12(1):72-81.

27. Chiche G. Improving marginal adaptation of provisional restora-tions. Quint Int 1990;21(4):325-329.

28. Yuodelis RA, Faucher R. Provisional restorations: An integratedapproach to periodontics and restorative dentistry. Dent ClinNorth Am 1980;24(2):285-302.

29. van der Velden U. Location of probe tip in bleeding and non-bleeding pockets with minimal gingival inflammation. J ClinPeriodontol 1982;9(6):421-427.

30. Lee EA. Predictable elastomeric impressions in advanced fixedprosthodontics: A comprehensive review. Pract Periodont AesthetDent 1999;11(4):497-504.

31. Listgarten MA. Periodontal probing: What does it mean? J ClinPeriodontol 1980;7(3):165-176.

32. Roach RR, Muia PJ. Communication Between Dentist andTechnician: An Esthetic Checklist. In: Preston JD. Perspectives inDental Ceramics: Proceedings of the Fourth InternationalSymposium on Ceramics. Carol Stream, IL: Quintessence Pub-lishing; 1988:445.

33. Paul S J. Smile analysis and face-bow transfer: Enhancing aes-thetic restorative treatment. Pract Proced Aesthet Dent 2001;13(3):217-222.

34. Jun SK. Shade matching and communication in conjunction withsegmental porcelain buildup. Pract Periodont Aesthet Dent 1999;11(4):457-464.

35. Aiba N. Fabrication of custom-made ceramic restorations usingWilli Geller’s Technique. Quint Dent Technol 1992;15:47-56.

36. Aoshima H. Aesthetic all-ceramic restorations: The internal live staintechnique. Pract Periodont Aesthet Dent 1997;9(8):861-868.

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these types of scenarios and those where adjunctive pro-cedures are performed primarily in pursuit of aestheticobjectives. While not unchallenging, the delivery of aes-thetic results in the absence of pathology or dysfunctionconstitutes an altogether different endeavor.

Generally accepted treatment planning conceptsorganize the sequence of therapy into phase I, aimedat initially addressing existing and active diseaseprocesses, followed by phase II, which includes correc-tive and restorative procedures. This traditional com-partmentalization of treatment and thought process is notconducive to the achievement of aesthetic outcomes inmultidisciplinary scenarios. Instead, the introduction ofthe aesthetic blueprint and its development during thediagnostic phase, as well as strict adherence to an aes-thetically oriented outcome-based methodology, will resultin enhanced integration of the specialties. This approachrequires that all adjunctive procedures be designed tosupport the previously defined aesthetic endpoint. Thuslyconceived, specific clinical objectives are identified forevery member of the clinical team. As a matter of clini-cal practicality, therapeutic aids must be provided toallow every specialist to intraoperatively verify compli-ance with the blueprint. The clinical challenge consistsin ensuring that aesthetic design continuity will be pre-served through the various therapeutic phases leadingto completion of a final restoration that satisfies all func-tional requirements.

AcknowledgmentThe author declares no financial interest in any of theproducts cited herein.

References1. Roblee RD. Interdisciplinary Dentofacial Therapy: A Comprehensive

Approach to Optimal Patient Care. Carol Stream, IL: Quin-tessence Publishing, 1994.

2. Rufenacht C. Fundamentals of Esthetics. Carol Stream, IL: Quin-tessence Publishing, 1990.

3. Chiche G, Pinault A. Esthetics of Anterior Fixed Prosthodontics.Carol Stream, IL: Quintessence Publishing, 1993.

4. Touati B, Miara P, Nathanson D. Esthetic Dentistry and CeramicRestorations. London, UK: Martin Dunitz, 1998.

5. Garber DA, Belser UC. Restoration-driven implant placementwith restoration-generated site development. Compend ContEduc Dent 1995;16(8):796,798-802,804.

6. Daftary F, Bahat O. Prosthetically formulated natural estheticsin implant prostheses. Pract Periodont Aesthet Dent 1994;6(9):75-83.

7. Beyron HL. Occlusal changes in adult dentition. J Amer Dent Ass1954;48:674-686.

8. Lamarck JB. Philosophie Zoologique. Paris, France: MuseeNational d’Histoire Naturelle, 1809.

9. Darwin CR. On the Origin of Species by Means of NaturalSelection. London, UK, 1859.


1. In contemporary restorative dentistry, rather than“form follows function,” it may be more appropriateto state that:a. This equation is not applicable in restorative dentistry.b. Form must be subordinated to function in all

medical sciences.c. New algorithms must be developed to define the

relationship between form and function.d. Form is such an important consideration that it should

supercede all functional requirements.2. In order to optimize aesthetic results, orthodontic

therapy should be ultimately driven by:a. The patient’s aesthetic desires.b. The Frankfurt horizontal plane.c. Anterior tooth display considerations.d. None of the above.

3. An outcome-based aesthetic treatment plan ischaracterized by:a. Development of an aesthetic blueprint in the diagnostic

phase.b. A departure from traditional phase I/phase II treatment

sequences.c. Adjunctive treatment designed to support the desired

aesthetic outcome.d. All of the above.

4. According to this article, a critical factor for the preservation of aesthetics through the multidisciplinarytreatment process is:a. Enhanced communication with the dental laboratory.b. Ensuring the team arrives at a diagnostic consensus.c. The recruitment of specialists from several disciplines.d. A cohesive clinical team working with a clinically

relevant aesthetic blueprint.5. Orthodontic therapy is utilized in the treatment of

periodontally compromised teeth to:a. Optimize tooth alignment prior to splinting.b. Correct the emergence profile of the abutment teeth.c. Improve interarch relationships as well as soft

tissue profile.d. Favorably modify osseous defect morphology

through forced eruption.

6. Currently, the most predictable way of regeneratingdeficient gingival papillae is:a. The double pedicle flap technique.b. Orthodontic therapy in conjunction with interproximal

ameloplasty.c. Use of an allograft membrane over a particulate

bone grafting material.d. None of the above.

7. The evaluation of clinical scenarios suggestive ofrapidly progressive periodontitis require:a. A special periodontal probing technique.b. Electron microscopy and immunofluorescence analysis.c. Sequential digital radiography and sulcular fluid

flow measurements.d. Bacterial sampling and culture, followed by adjunctive

antibiotic therapy.

8. In any situation where the relocation of gingivalmargins is being considered, it is essential to:a. Have provisional restorations with precise margins.b. Preview the expected results with diagnostic imaging.c. Ensure that the appropriate type of laser is selected.d. Perform bone sounding to identify the location of

the osseous crest.

9. The transfer of anatomic details developed in the provi-sional restoration to the definitive prosthesis is ensuredthrough the use of:a. Accurate photography.b. A thorough record of all modifications implemented.c. Precise measurements utilizing calibrated instruments.d. None of the above.

10. It is imperative to utilize an aesthetically oriented face-bow transfer technique because:a. Full pantographic registration is technique sensitive.b. The bipupillary line must be registered with precision.c. Interchangeability between semi-adjustable articulators

will be ensured.d. The relationship between the occlusal and horizontal

planes must be accurately captured.

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mailit to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.

The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article: “Aesthetic design preservation in multi-disciplinary therapy: Philosophy and clinical execution” by Ernesto A. Lee, DMD, and Sang K. Jun, CDT. This article is on Pages 561-569.

Learning Objectives:This article illustrates the clinical techniques and sequence for an outcome-based protocol that allows the establishment and preservationof aesthetic objectives in multidisciplinary therapy. Upon reading this article and completing this exercise, the reader should:

• Understand the restorative guidelines for achieving successful multidisciplinary treatment involving periodontal, orthodontic, andlaboratory-based disciplines.

• Be aware of the requirements for the development of an outcome-based treatment plan.

CONTINUING EDUCATION

(CE) EXERCISE NO. 21CE

CONTINUING EDUCATION

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AESTHETIC DESIGN PRESERVATION IN ... Design...AESTHETIC DESIGN PRESERVATION IN MULTIDISCIPLINARY THERAPY: PHILOSOPHY AND CLINICAL EXECUTION Ernesto A. Lee, DMD* Sang K. Jun, CDT†