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Esthetics Considerations
BY
Mostafa Elhossieny Mohammed
Definition
Interest of Esthetic
Esthetic formula ( Principles)
Esthetic Elements
It is the appreciation of beauty.
It is NOT absolute but it is extremely subjective.
It differs from individual to another & between
different cultures.
As one perceived as disfigured may be beautiful
to another.
Esthetics
In dentistry, it is the art of coping or harmonizing
our work to naturality.
Interest of Esthetic
Why do we interest
by esthetics?
It is the primary motivating factor for
patient seeking dental care
Correction of esthetic problems has a
positive effect on the self-confidence
The mouth is a focal point of any emotional
responses.
Stop hiding your teeth.
Development in
restorative materials,
adhesive technology
The advancements of
ceramic materials
and techniques.
It is part of the mouth where high visibility requires a restoration.
It includes Mx. Anteriors , premolars and frequently Mx. 1st molar.
It depends on mouth size, smile width, lip tightness and tooth length
Appearance Zone
Recolor: The first option is tooth whitening.
Reposition: The second option is orthodontic
repositioning.
Recontour: The third option is to recontour teeth and
equilibrate.
Restore: Once the above options have been explored, the
last option is to restore the teeth with veneers or crowns.
Smile should express your:
Personality
Emotions
Inter-action in the society
Peacefulness
Happiness
Confidence
Stable muscular structure, joints and skeletal.
Harmony
Esthetic Formula
It is a function of harmony between
* The ideal smile represents a maximum harmony
between facial composition and dental composition.
* The goals in the last 20 years to search for standard
parameters to help in diagnosis , evaluation and
resolving the esthetic problems of the smile.
Smile analysis should be done :
• Direct photo Digital• (in patient mouth) (optional)
• Combination of the three elements can be
achieve best results.
Steps of smile analysis:
• 1- Meeting the patient and understanding his
requirements.
• 2-Medical and dental history.
• 3-questionnaire
• Problems and demands
• Why the patient is not happy with his smile (shape , color
,…etc)and what is expected
• Emotions and personality ( happy , sad , timid)
• 4-Clinical examination, x ray and phonetics
evaluation.
• 5- dental photography.
• Proper frontal picture of the patient using DSLR camera , ring
or twin flash , reflectors and contractors.
• Shots should be in upright frontal view .
Esthetic Elements
Smile parametersfacial composition
Dental midline
Occlusal plane
Smile line
Commissural line
Gingival display and upper lip
Gingival level and harmony
Axial inclination of the teeth
Zenith of the gingival contour
Incisal length and width
Buccual corridor
Tooth morphology
Sex and age
Personality
Occlussion
symmetry
I-Facial Esthetics
1-Facial Midline
The face is divided
into 2 equal vertical
halves by the midline.
For optimal esthetics,
the upper central
incisors midline must
coincide with this
midline
The face is divided
into 5 equal vertical
lines
2-Rule of Fifth
3-Facial Height
The face can be
divided into 3 thirds.
This is the perfect
proportion of a
beautiful faces.
Loss of vertical
dimension of occlusion
(lower third of the
face), the facial
esthetic proportion is
NOT optimal
Increasing vertical dimension of occlusion can have
positive effects on facial esthetics, not just on the
peri-oral areas but on the whole face
4-Width of Smile
2 Vertical lines from
the pupil of the eye to
the corner of the
mouth. This will be
ideal width of the
mouth on smiling.
II-Gingival Esthetics
Esthetic conditions related to the gingival health
and appearance is an essential component of
effective smile design.
Pink esthetics (the gum) is as important as
white esthetics (the teeth) specially with shorter
lip patient that exposes the gums on smiling
The cosmetic dentist will take into consideration
the relationship between pink and white
esthetics during the smile design stage.
Inflamed, uneven gingival lines detract from a pleasing smile
It refers to the position of the inferior border of the
upper lip during smile formation.
Amount of Gingival Display
1-Lip Line
Medium lip line.
Low lip line.
High lip line
An imaginary line along the incisal
edges of the maxillary anterior
teeth which should mimic the
curvature of the superior border of
the lower lip during smiling.
2- Smile Line
3-Lip Dynamic
It is the curvature of the lip
It become noticeable by taken video.
It determined :
Tooth – lip relation at rest
Tooth – lip relation at smiling
Lip support
A- wide dynamic B- restricted dynamic
It must mimic the
silhouette of the natural
dentition, in the gingival
one third, extending from
the base of the gingival
sulcus past the free gingival
margin into the oral cavity.
4-Emergence Profile
A proper emergence profile will help avoid
swelling , inflammation of soft tissue and
prevent the appearance of dark spaces in the
cervical (gingival) embrasure.
It is the apical most points of the gingival margins, and it’s located 1mm
distal to the long axis of the tooth ( except 2,4 & 5 midway)
5-Gingival Zenith
When closing diastema
The zenith points should be mesially repositioned
to avoid a mesially tilted appearance.
This can be achieved with minor-gingival
alteration at the time of, or prior to, the tooth
preparation.
– It is an imaginary line
drawn by joining the
zeniths of central incisors
and canines. (0.5-1 mm
shorter for lateral incisors)
– Differences between the
heights of the apical
gingival margins of the
anterior teeth, determining
the ideal gingival contour
for the region.
6-Gingival Line
The gingiva height at
the same level over of
the laterals , canines
& central ► is
acceptable
The gingiva height
over the laterals is
apical to that of the
canines or central or
both( Reverse )
► NOT accepted
There are normal variations in the thickness of
and the resistance to recession of gum tissue.
"Thick Biotype", which is very unlikely to
recede or to lose the gum papillae between the
teeth.
"Thin Biotype" that is very susceptible to
recession and loss of the gingival papillae
between the teeth.
7- Gingival Biotypes
Thick Biotype
Thin Biotype
When doing veneers, or crowns on teeth with the thin
biotype ► extreme atraumatic care with a higher end
laboratory technician is necessary to prevent loss of tissue.
III-Macro and Micro-Esthetics
Macro-esthetics represents the principles that
apply when group of individual teeth are
considered.
Macro-esthetics attempts to identify and
analyze the relationships & ratios between
anterior teeth and surrounding tissue
landmarks.
Macro- Esthetic
Cultural Basic Artistic Basic
(Age, Sex & Personality )
A) Cultural Basic
(Age, Sex & Personality )
Older teeth Younger teeth
A) Cultural Basic
(Age, Sex & Personality )
1-Age:
MASCULANE FEMININE
2-Sex
The classic chart from Lombardi, illustrating the
SPA factor.
Age:
Youthful teeth: unworn incisal edge, defined incisal embrasure, low chroma
and high value
Aged teeth: shorter; so less smile display, minimal incisal embrasure, high
chroma and low value
Sex :
Female form: round smooth, soft delicate
Male form: cuboidal, hard vigorous
Personality :
Aggressive, hostile angry: pointed long “fangy” cusp form
Passive, soft: blunt, rounded, short cusp form
B)Artistic Basic(Principle of lines)
( Principle of illumination)
It refers to the vertical contact interface
between two maxillary centrals.
1-Dental Midline
– It should be perpendicular to the incisal plane, parallel to
the facial midline, and dropping straight down from the
papilla.
Maxillary and mandibular midlines do NOT
coincide in 75% of cases.
Mismatch between them does NOT affect
esthetics…. WHY????
since mandibular teeth are NOT usually visible
while smiling.
Minor discrepancies
( < 4mm) between facial and dental midlines
are acceptable and, in many instances, not
noticeable.
Slanted mid-line Slanted &shifted
mid-line
Minor discrepancies ( < 4mm)
between facial & dental
midlines can be accepted
WITHOUT slanting
It is the most important determinant in smile creation because once set, it serves
as a reference point to decide the proper tooth proportion and gingival levels.
2-Incisal Edge Positions
( Incisal Plane )
The incisal edge positionof the lateral is placed0.5 to 1 mm apicallycompared to central andcanine in youngdentitions.
The incisal plane shouldbe parallel to the inter-pupillary line.
Correct incisal edge position is crucial ► it is
related to the area of the anterior teeth, labial
contours, lip support, anterior guidance,
lingual contours and tooth display
It compares the vertical alignment of maxillary teeth, visible in the smile line, to
central vertical midline.
3-Axial Tooth Inclinations
Arrangement of the zenith defined by the inclinations of the long axis of the
upper anterior teeth. Papilla between the central incisors filling the space
until half of the height of the crowns of these teeth and gradually reducing in
height to distal.
It is progressive increase in the mesial
inclination of each subsequent anterior tooth.
It should be least noticeable with the centrals
and more pronounced with the laterals and
slightly more so with the canines.
Distal inclination of the root apex when
compared to vertical midline
Interproximal Contact Area (ICA):
(Connector space)
4-Interdental Contact Area & Point
Between maxillary central incisors ►
50% of the length of central incisor,
Between a maxillary lateral incisor and a
central incisor ► 40% of the length of
the central incisor.
Between a maxillary canine and a lateral
incisor ► 30% of the length of the
central incisor
The Ideal Connector Size:
The position of anterior contact point should
progress from incisal to cervical from centrals to
canines.
The incisal embrasures should display a natural, progressive increase in size
or depth from the central to the canine.
5-Incisal Embrasures
The contact point moves apically as we proceed
from central to canine.
A distal incisal corner is more rounded than its
mesio incisal corner.
Also, if the incisal embrasures are too deep, it
will tend to make the teeth look unnaturally
pointed
5 mm only
between the
crestal bone &
contact area if
more black
triangle will be
appear.
Facial view, the width of each anterior tooth is 60% of the width of
the adjacent tooth (mathematical ratio being 1.6:1:0.6).
6-Golden Proportion
Limitations of Golden Proportion
It is mainly based on the tooth width in frontal view
ONLY,
NO tooth height
NO profile or side view
Difficult to apply as patients have different arch form,
lip anatomy & facial proportions.
Appearance the limitations of Golden
Proportion clearly with attration.
It dictates that the centrals must be the dominant teeth in the smile (key of
smile)
W/L of the centrals = 4:5 (0.8–1.0)
Width of 75–80% of Length.
7-Recurring Esthetic Dental Proportion
(RED Concept)
BUT,, Tooth proportions
are width & height
The gauges allow for fast & simple analysis of tooth width, tooth length and
gingival length .
CHU’S proportion guide
9-Buccal Corridor
(Negative Space)
It refers to dark space visible during smile formation between the corners of
the mouth and the buccal surfaces of the maxillary teeth.
It should be a minimum.
10-Phonetics
It is a major determinant of the tooth length.
” Minimal tooth reveal”
“Maximum extension of lips”
“Overjet,overbite----rest”
“Mx.Incisors & wet-dry border
of lower lip”
FACTORS that affecting esthetics in
dental restorations
1-Soft tissue management.
2- Tooth reduction.
3-Shade matching.
4-Tooth color and variation
5- Translucency
6-Tooth form, size and position.
7- Degree of gloss .
8-Surface characterization .
9-Illusion and perceived size
Subgingival finish line is indicated for esthatic.
Every effort to produce Subgingival finish line
with minimal soft tissue injury during:
* Retraction Cord Technique.
* Impression Procedure
* Temporary Restoration
* Soft Tissue Response to Final Ceramic
Restoration.
1-Soft Tissue Management
Retraction cord is
placed into sulcus to
temporary lateral
displacement of
gingiva.
To reduce the soft
tissue injury
A-Retraction Cord Technique
Used proper cord size & atraumatic packing
pressure
With healthy gingiva:
Small sized ( anterior teeth )
Single medium sized ( posterior teeth )
Never use too large retraction cord or too
many cords ► caused excessive trauma.
Tissue blanching is
observed immediately
after cord placement &
rapidly disappears.
Prolonged blanching ►
detrimental gingival
changes
An impression must provide detailed
information about the prepared teeth ,
surrounding intact teeth & associated sot tissue.
So, we must record the gingiva as natural
position as possible.
To allow fabrication of restoration without
gingival recession or any adverse reaction to
gingiva.
B- Impression Procedure
For best gingiva record :
Remove of cord from sulcus
& Syringed the impression around the
prepared tooth.
After removal of impression , checking that NO
remnants occur ► To avoid sever tissue
reactions
Temporary restoration must be proper contour
, adapted well to preparation margin and
smooth surface to promote maintainace tissue
position & health.
Allow cervical embrasures ► for oral hyigene
aids
Time of lift of temporary restoration NOT
excess than 2-3 weeks.
C- Temporary Restoration
Poor soft tissue response around a
cemented restoration ►poor esthetics.
It may be due to :
over extended or under extended
margin ► plaque accumulation.
D-Soft Tissue Response to Final Ceramic
Restoration.
2- Tooth Reduction
Facial reduction in
2 planes
Sufficient Facial
reduction of
ceramic restoration
(1-1.5 mm)
Inufficient Facial reduction, laboratory can be
handling by :
* Over contoured restoration ► plaque acc.
*Inadequate porcelain thickness►↓ esthatic.
( can be enhanced by color modification )
3- Shade Selection
The tooth reduction is insufficient.
A poor selection.
The dental laboratory may have failed to
reproduce the shade.
Also, the porcelain may not have been handled
in such a manner as to reveal its inherent
coloration
Poor Color Match due to:
4-Tooth Color & Variation
1- Maxillary anterior teeth
Pigmentations : Canines > Central > Lateral
2- Mandibular anterior teeth
Pigmentations : Canines > Central & Lateral
(If a variation in the incisors exists, it is the opposite
of that found in the maxillary incisors)
3-Posterior teeth
Pigmentations : molars > premolars
(Same degree of pigmentation <canine).
Among the Teeth:
Degree of pigmentation of anterior teeth
are different
Degree of pigmentation of posterior teeth
are less than canine
Pigmentations : gingival third > Incisal
( variation on enamel thickness)
Within the Tooth:
5-Translucency
Appearance of vitality.(alive tooth)
High translucency ► incisal edge, cusp tip &
proximal surface.
The translucency terminate gradually
It is important to duplicate that specially with
low lip line pt. ( due to it is the obvious part of
restoration )
A halo (incisal edge opacity), contrast to
the translucency
6-Surface characterization
Surface texture is affected by age
Light reflection plays a role in surface texture
Developing the desired light reflection on a
restoration’s surface by duplication of the
heights of contours and depressions on the
facial surface.
By close-up photographs taken from different
angles .
Surface texture is affected by age
Black and white photographs are helpful
in determining Value,
7- Degree of Glossy
It enhances the natural appearance of the
restoration as it affects the reflection of light.
Excessive gloss lightens the color
Too long heating or heating at elevated
temperatures during glaze firing ► exaggerated
gloss.
Introducing highly glazed wear facets in older
patients ► improves esthetics.
Introducing highly glazed wear facets in older
patients ► improves esthetics.
8- Tooth form, size and position. It is usually better for restorations to be shaped
like their contra-lateral teeth.
Slight alterations in form and position to escape
from artificiality.
9- Illusion and perceived size .
Art of changing the perception to cause an
object to appear different than it actually is.
It helps in solve space problems ( too much or
too little ).
Principles of lines:
- Horizontal lines ► ↑ Width illusion
- Vertical lines ► ↑ Length illusion
- Flat incisal edge ► ↑ Width illusion
Canine tip :
- Mesially► ↑ small & narrow tooth illusion
- Distally► ↑ large tooth illusion
Staining:
- Darkening at the transitional line ►
narrow& small tooth illusion
