ESTHETICS IN

FIXED PARTIAL PROSTHODONTICS

Presented by : Hemal Patel

Guided by : Dr. Smita Athavale

1

CONTENTS

1.Definitions2.General principles of Esthetics3.Factors of esthetic dentofacial composition4. Esthetic considerations for Pontics5. Esthetic considerations for Connectors6. Surgical & non-surgical methods to improve

esthetics7. Types of esthetic restorative materials8. Esthetic fixed restorations9. References

2

ESTHETICSBranch of philosophy dealing with beauty.

Esthetic dentistryArt and science of dentistry applied to create or enhance the

beauty of an individual within functional and physiological limits.

Why needed in fixed partial prosthodontics? ? ?

3

Appearance Zone :

•This is the anterior oral area where esthetics is of prime

concern & which is visible on smiling, from maxillary premolar to

premolar (usually 1st molars also),.

•Depends on the person’s self-image, mouth size, teeth size,

smile width, lip size and tightness.

4

GENERAL PRINCIPLES OF ESTHETICS1.Composition :

Facial composition Dentofacial composition Dental

composition

2.Unity:

i. Static unity ii. Dynamic unity

The following visual forces play a role in unity.i. Cohesive forces

ii. Segregative forces5

Thus, to achieve unity, the teeth are arranged with tectonic

spacing, that is, an esthetic and functional arrangement.

Centric occlusion Anterior protrusion of the mandible

3. Symmetry: Regularity in the arrangement of forms or

objects.

i. Horizontal symmetry

ii. Radiating symmetry

6

4. Color, form and lines:

These provide dominance to a composition.

Color predominates over forms, lines and angles.

According to A. H. Munsell,

CHROMA

HUE

VALUE

Specific color produced by a specific

wavelength acting on the retina.

SATURATION : Purity of a color.

BRILLIANCE : Lightness or darkness of a color.

7

MUNSELL’S COLOR WHEEL

Many factors that are part of biologic or structural beauty

depend on the visualization of LINES.

The direction of lines can also create optical illusions.

Vertical lines = longer tooth

Horizontal lines = wide and short tooth

Imaginary anterio-posterior line

of the incisal edges/cusps tips

representing the curve of Spee

Lines & Planes

9

Any FORM can be created from the three basic shapes of a

circle, triangle and square.

10

5. Proportion and Ratios:

Golden Proportion: The Golden Proportion results from the

division of a straight line in such a way that the shorter part is

to the longer part as the longer part is to the whole. Each ratio

equals 0.618.CB/AC = AC/AB = 0.618

AC

B

A/B = A+B/ C = C/B = B+C/A

= 1.618 = phi

Golden Rectangle

Golden mean gauge

11

FACTORS OF ESTHETIC DENTOFACIAL COMPOSITION

A. FACIAL COMPONENTS

B. DENTAL COMPONENTS

C. GINGIVAL COMPONENTS

D. PHYSICAL COMPONENTS

A.FACIAL COMPONENTS:

1. References:

a. Horizontal references

-Interpupillary line

-Ophriac line

-Commissural line

b. Vertical references:

-Facial midline

12

c. Sagittal references:

Upper and lower lip contours

E-line

d. Phonetic references:

"M" sound: amount of incisal display at rest.

"F" or "V" sounds: lingual tilt of the maxillary central incisor

length.

"S" and "Z" sounds: vertical dimension of speech.

13

2. Facial Proportions:

14

3. Visibility:

•The amount of tooth exposure when lips part slightly in a

relative rest state governed by muscles.

•Age

•Short upper lips : upper incisors

•Long upper lips: lower incisors

4. Components of the Smile:

a. Lip line :

Upper lip line:

• Exposure of teeth at rest/smiling and gingival margins on

smiling.

• Evaluate the need for esthetic gingival contouring/crown

lengthening in anterior area.15

Young Old

Lower lip line helps to evaluate buccolingual position of the

incisal edge of the maxillary incisors and the curvature of the

incisal plane.

b. Incisal plane:

Convex

Gull wing effect

c. Incisal edge position:

16

INCISAL EDGE POSITION AT REST ON SMILING

d. Smile line or incisal curve is composed of the incisal edges

of the maxillary anterior teeth and parallels the inner curvature

of the lower lip.

•Degree of curvature more pronounced

in women than in men.

e. Negative space:

17

f. Smile symmetry:

•Perceived in reference to central midline.

•Horizontal and radiating symmetry.

•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.

18

B. DENTAL COMPONENTS:

1. Dental midline :

•Anatomical landmarks like the incisive papilla or

the labial frenum..

•Not necessarily should coincide with facial midline.

•Balance and symmetry.

2. Tooth proportion:

•Golden proportion (61.8 %)

•Proportion determined by face form

•Proportion by statistical averages

(75-89%)

19

“A” 85% ratio, square appearance.“B” 78% ratio, normal ratio.“C” 65% ratio, teeth appear taller.

3. Axial inclination:

20

4. Teeth arrangement:

10.2 mm

21

Arch form

5. Gradation :

Front-back progression

22

6. Teeth morphology :

a. Contact area:

b. Texture :

• Texture can be noted by the light reflection

pattern.

• The surface texture of a crown should simulate

the reflectance pattern of the adjacent natural teeth.

23

c. Characterization :

According to age, sex and

personality.

d. Embrasure form : facial, lingual, incisal and gingival

embrasures.

•Affects perception : large embrasures make tooth appear

smaller and vice versa.

•Incisal embrasures increase in size from central incisor to

canine.

24

Frush and Fisher Rufenacht

e. Line angles:

•Transition from the labial surface at the

mesial and distal lobes to the interproximal

embrasures.

•Changes in their positions control

the appearance of the width of the tooth

and affect light reflection pattern.

f. Emergence Profile:

A tooth's emergence profile is the angle at which the tooth

emerges from the gums when viewed from the side.

25

7. Symmetry:

Automatically obtained if previous

principles are followed.

26

C. GINGIVAL COMPONENTS:

•Gingival line

•Gingival apex/zenith

•Gingival contour and scalloping

•Gingival embrasure

•Gingival symmetry

27

D. PHYSICAL COMPONENTS:

Perception:

Visual perception is:

•· Increased by increasing contrast

•· Increased by increasing light reflection

•· Increased by decreasing light deflection

Illusion:

•Is the art of changing perception making an object appear

different than it actually is.

•Principle of Illumination

•Principle of Lines

•Solve/hide esthetically difficult situations.

28

NARROWING

WIDENING

SHORTENING

LENGTHENING

COLOR:

1. BASE COLOR :Base color is selected on the basis of hue, chroma and value selectionusing shade guides and tabs, comparing with adjacent teeth.

2. INTERPROXIMAL :Interproximal color provides a silhouette for the tooth.Dark colors makes teeth look smaller while no change in color will give abroader appearance.

30

3. GINGIVAL THIRD :•Enamel gets thinner in the gingival third of teeth so darker dentinshows through and the area looks more yellow.•Staining .

4. INCISAL EDGE :The incisal edge is translucent enamel resulting in translucency, a haloeffect, or no change as it is worn away with age.

5. CHARACTERIZATION :•There are many different colors which can occur within a tooth asmight be seen with craze lines or hypocalcifications.•Staining.

31

TRANSLUCENCY:

•Degree to which light is transmitted rather than reflected.

OPALESCENCE:

•Important component of the perceived enamel colour•Subtle bluish gleam characteristic appearance.

32

Guidelines for shade selection:

• Stains and deposits must be cleaned off the tooth, and the tooth must be kept wet throughout shade determination.

•Remove bright make-up like lipstick and use neutral-colored drape to avoid distraction.

•The teeth should be viewed at eye level so that most color-sensitive part of the retina will be used.

• The color of the luting agent must also be taken into consideration.

33

•· Shade evaluation :

-First visit after cleaning OR Next visit after tooth preparation or bleaching or a strenuous appointment, but following color stabilization.

-Under different lighting conditions and wet conditions.

•· Hue, chroma and value 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.

•First impression of the chosen color is best and sometimes, squinting may help to choose the right value of color.

•Shade tabs :

•Custom shade guides •Photographs

ESTHETIC CONSIDERATIONS FOR PONTICS

36

FACTORS AFFECTING PONTIC DESIGN

A. Pontic spaceB. Residual ridge contourC. Occlusal load

A

B B C

SURGICAL MODIFICATION FOR RIDGE DEFECTS

ROLL FLAP TECHNIQUE

•The Roll Flap Technique to Improve Esthetics in Anterior Ceramic Fixed Partial

Dentures: Perio-Prostho Relationship - A Case Report

Kalpesh Vaishnav, Anita Panchal, Dipti Shah

POUCH TECHNIQUE

INTERPOSITIONAL GRAFT

Free gingival

graft

PONTIC DESIGN

B. Mesiodistal width C. Gingival interface

A. Inciso-gingival height

ESTHETIC PONTICS

Saddle / Ridge lap pontic

•Esthetics : Resembles a tooth &

replaces all the contours of the

missing tooth .

•Concave tissue surface.

•Overlaps the residual ridge

buccolingually.

•Disadvantage : Difficult flossing due

to concave tissue surface.

Modified ridge lap pontic• It combines the best features of the hygienic

and saddle pontic designs, combining esthetics with easy cleaning.

• Overlaps the residual ridge facially only.

• Lingual surface has a slight deflective contour to prevent food impaction and minimize plaque accumulation.

.

• “T” shaped tissue contact whose vertical arm ends at the crest of the ridge.

Ovate pontic

• First described by DEWEY and

ZUGSMITH in 1933.

•Most esthetically appealing pontic

design and ease of hygiene.

•Convex tissue surface resides in a softtissue depression or hollow in theresidual ridge.

•Appears to grow out of ridge.

PONTIC INDICATION ESTHETIC CONCERN

HYGIENE DIAGRAM

Saddle-ridge lap

Anterior and Posterior teeth

Reasonablygood esthetics

Difficult

Modified ridge lap

Easier than above

Ovate

Anterior and Posterior teeth;

High lip line

Excellent esthetics & emergence profile

Easier than above

45

Use of a Modified Ovate Pontic in Areas of Ridge Defects

CHIUN-LIN STEVEN LIU:J Esthet Restor Dent 16:273-283, 2004

A modified ovate pontic has the following advantages:

•Excellent esthetics•Fulfilled functional requirements•Greater ease of cleaning as compared with the ovate pontic•An effective air seal, which eliminates air or saliva leakage•The appearance of a free gingival margin and interdental papilla•Elimination or minimization of the "black triangle" between the teeth•Little or no ridge augmentation required.

46

Ponticsystem

Advantages Disadvantages Indications Contraindications

Metal-ceramic

Esthetics

Biocompatible

Difficult if an abutment is not metal-ceramic Weaker than all metal

Most situations Long spans with high stress

All metals Strength Non-esthetic Mandibularmolars especially under high stress

Where esthetics is important

Fiber-reinforced all-resin

Conservative when used with inlay preparations

Esthetics

Easy to repair

Long-term success unknown Limited to short spans

Areas of high esthetics concern

Long-span FPDs

Facings Rarely used

Available Pontic Systems

ESTHETIC CONSIDERATIONS FOR CONNECTORS

A. Connector size

B. Connector shape

C. Connector position

Connectors are components of FPD that connect the pontic(s) to retainer(s).

-Rigid-Non-rigid

Fig 1 Fig 2

49

ESTHETIC PERIODONTAL CORRECTIVE PROCEDURES

Inadequate tooth structure for restoration:1.surgical crown lengthening2.Forced eruption with fiberotomy.

Recession:1.Free gingival / lateral pedicle graft2.Subepithelial connective tissue graft3.Guided tissue regeneration

Edentulous ridge defects:1.Onlay/inlay grafts2.Synthetic bone grafts

Gingival overgrowth:1.Gingivectomy / Gingivoplasty2.Apically postioned flap with or without ostectomy

Electrosurgery/laser for

esthetic contouring

•Pontic design:-Tooth-colored-Pink ceramic in cervical area

•Gingival mask

•FPDs with pink porcelain flanges

ESTHETIC NON-SURGICAL CORRECTIONS

TYPES OF ESTHETIC RESTORATIVE MATERIALS

1. Ceramic :- Aluminous- Feldspathic reinforced with Zirconia- Feldspathic reinforced with Leucite- Ceromers

2. Composite : - Conventional- Fibre-reinforced (glass, polyethylene, carbon)

3. Gingiva-colored materials:- Ceramic like d.SIGN- Acrylic- Silicone

ESTHETIC FIXED RESTORATIONS

Missing teethCrowding/Malaligned anteriorsMild rotationsStains/DiscolorationAbrasions/Attrised anteriorsErosions/Destructed toothSpacing

BridgesOnlaysCrownsVeneers/Laminates

INDICATIONS

ESTHETIC FIXED RESTORATIONS

Full-coverage FPDPartial-coverage FPDResin-retained FPDFibre-reinforced composite FPDImplant-supported FPD

54

Metal-ceramic All-ceramic

METAL-CERAMIC RESTORATIONS

Facial Tooth Reduction:

•A minimum reduction of 1.5 mm typically is required for optimal

appearance.

Reduction in 2 distinct planes Adequate porcelain thickness

55

Incisal Reduction:

•An incisal reduction of 2 mm is recommended for translucency

at the incisal 1/3rd.

•Excessive incisal reduction must be avoided because it reduces

the resistance and retention form of the preparation.

56

Proximal Surface:

The proximal surfaces of these

anterior metal-ceramic crowns are

restored in porcelain, which allows

light to be transmitted for

maximum esthetics.

Margin Placement:

Should follow free gingival contour.

Supragingival margins :

Easy to prepare, finish, maintain hygiene, make impressions

and evaluate on recall visits.

Low lip line.

Subgingival margins:

Caries/restorations involving root High lip line.57

Proximal margin:

Mesial margin: just buccal to the proximal contact area, where

metal will be hidden by the distal line angle of the neighboring

tooth.

Facial margin:

•Just beyond the occlusofacial line angle.

•Short bevel (to prevent enamel chipping)

•Chamfer (for more bulk of material in molars, if needed)

58

PARTIAL-COVERAGE RESTORATIONS

Fiber-reinforced composite fixed partial restoration

Consists of a fiber-reinforced composite substructure veneered with a particulate composite material.

Resin-retained fixed partial restoration

Short span FPDs supported by thin metal retainers bonded linguallyand proximally to the abutment enamel.

Etched resin-retained (Maryland bridge)

Cast perforated resin-retained fixed

IMPLANT-SUPPORTED BRIDGES

LAMINATES/VENEERS

AFTERBEFO

RE

62

BEFORE AFTERPORCELAIN

COMPOSITE

ARTICLES

Collarless metal ceramic fixed partial denture: Clinical

report.

W. Matsumoto et al.

Braz Dent J (2001) 12(1) 215-218.

• Advantages:

- Esthetic

- Excellent biocompatibility of the glazed porcelain

- No special equipment required.

- Less plaque because of smooth glazed porcelain collar.

• Although, it requires skill and there is always the risk of

producing restorations with poorer marginal fit.

•An Alveolar Bone Augmentation Technique to Improve Esthetics in Anterior Ceramic FPDs: A Clinical ReportBurak Taskonak and Yasar OzkanJ Prosthodont 2006;15:32-36.

This article describes an alvelolar bone augmentation technique so as to preserve the edentulous space after extraction which is nothing but the pontic space.

Tissue sculpturing: An alternative method for improving esthetics of anterior fixed prosthodonticsJacques et al.J Prosthet Dent 1999;81:630-3.

•An unfavorable relationship between residual ridge, pontic, and gingival papilla commonly compromises the final result.

•This article describes a technique for the improvement of esthetics with conditioning of the tissue beneath the pontics, by displacing tissue with a treatment restoration.

•Lateral displacement of tissue under gradual, controlled pressure enhances the interdental papilla, which improves esthetics.

References

1. Fundamentals of Fixed Prosthodontics: Shillingburg 3rd

Edition.

2. Contemporary Fixed Prosthodontics : Rosenstiel 3rd Edition.

3. Library dissertation “Esthetics in FPD” by Dr. Guruprasad

Handal ; Dr. DY Patil Dental College.

4. South African Dental Technology Journal : Aesthetic s

Issue,Vol 1 Issue 3.

5. The art of a beautiful smile.

Journal of Cosmetic Dentistry, Fall 2008 Volume 24 Number

3.

6. Collarless metal ceramic fixed partial denture: Clinical

7. Use of a Modified Ovate Pontic in Areas of Ridge Defects:

Case reports.

Liu CS.

J Esthet Restor Dent 16:273-283, 2004.

8. Levin El. Dental Esthetics and the Golden Proportion.

J Prosthetic Dentistry 40:244-252 1978.

9. Lombardi RE. The principles of visual perception and their

clinical application to dental esthetics.

J Prost Dent. 1973;29:358-381.

10.McLaren EA and Tran Cao P. Smile Analysis and Esthetic

Design: “In the Zone”. Inside Dentistry- Esthetics,

July/August 2009.

11.The updated application of the golden proportion to dental

aesthetics.

THANK YOU

Next seminar by Dr. on

Resin-retained fixed partials:

Fiber-reinforced fixed partials:

Short span FPDs supported by thin metal retainers bonded lingually and proximally to the abutment enamel.

Consists of a fiber-reinforced composite substructure veneered with a particulate composite material.

Etched resin-retained (Maryland bridge) Cast perforated resin-retained fixed