Aesthetic restorations are now the most common reason for dental visits, along with pain management. The ubiquitous presence of social media constantly suggests new ideals of beauty. Against this background, dentistry has undergone a fundamental transformation from a purely restorative treatment to a more cosmetic and aesthetic focus. Dr. Catharine J Song, a cosmetic dentist in Beverly Hills and the owner of Song Cosmetic Dentistry at 300 S Beverly Dr Ste #401, Beverly Hills, CA., would like to provide a guideline for a cosmetic-aesthetic restoration based on a case study.
What do you call beautiful? The well-known quote "Beauty is in the eye of the beholder" (Thucydides, c. 455-396 BC) clarifies the definitional diversity underlying the term "beauty". There are a wide variety of parameters that are perceived as beautiful by a wide variety of people. It is therefore one of the central challenges to filter out the patient's wishes in a targeted manner in order to ultimately create the optimal harmony between face, mouth and tooth, which the patient perceives as aesthetic.
Therefore, the following shows how the aesthetic ideas and wishes of the patient can be optimized and implemented according to standardized aesthetic guidelines. The aim is to provide you with a guide to support you in aesthetic analysis, treatment planning and restoration.
Dentists have long tried to harmonize the shapes of the teeth with the patient's face, based on parameters such as gender, age, personality and individual expectations.
Therefore, the following central questions arise: What do I have to consider when planning treatment? How do I proceed? How do I find out which smile suits my patient? In order to make our procedure clearer to you, we will explain it to you step by step using a patient case.
Step 1: Patient presentation
After a detailed intraoral examination, the patient will already explain to you at the first appointment what his ideas and wishes are. Then you need to consider how to balance the necessary treatments with the patient's wishes. The necessary X-rays, photos or videos can help you with this. You can use these to deepen your planning. The advantage of this type of visualization has already been discussed in many different studies and processes, including with the DSD (Digital Smile Design) or Visagismo.
Step 2: Situation analysis and treatment planning
With the help of the patient recordings, you can now analyze and plan the need for treatment step by step. It's best to start with the most important aesthetic aspect and work your way down to the smallest detail.
centerline
Does the dental midline coincide with the center of the face? A deviation is usually perceived as disturbing by outsiders, which means that the dental midline is an important focus in an aesthetic restoration. To check, use a piece of dental floss to locate. You use the two anatomical landmarks nasion and base of the philtrum. If there is a centerline deviation, mark the correct position of the centerline. In addition to the facial photos taken, this marking is essential so that the technician can transfer the exact position of the midline to the new situation.
occlusal plane
The frontal occlusal plane (line connecting the canine tips) should be parallel to the bipupillary line. You can do this on the patient, e.g., B. using a wooden spatula and transfer it to the articulator by registering with a face bow.
gingiva
The most important gingival components of the smile are the color, contour, texture and height of the gums. Inflammation or uneven gum lines affect the aesthetic quality of the smile. Female lip lines are on average 1.5mm higher, i.e., 1-2mm of gum visibility when smiling can be considered aesthetic for women. It is important that the gingival margins of the central incisors are usually at the same level or slightly lower than those of the canines, while the zenith of the lateral incisors should be lower than that of the central incisors.
The average vertical height of the maxillary central incisor is 10.6 mm in males and 9.8 mm in females. Using calipers or a PA probe, the height of the clinical crown is determined and based on the smile line it is determined whether the teeth need to be adjusted coronally or incisally. The ideal length-to-width ratio is between 75 and 85 percent. If only a few or hardly any teeth can be seen at rest, the crown height can be increased incisally. Gingivectomy or surgical crown lengthening is recommended when short clinical crowns are associated with a gingival smile.
The adaptation of the red-white aesthetics is carried out in our patient by means of a gingivectomy. However, if the biological width is not sufficient, the method of surgical crown lengthening must be used in order to achieve a more harmonious overall picture. In both procedures, intraoral markings are helpful to visualize how much gingiva needs to be removed coronally.
Since in our patient case a gingivectomy has to be carried out anyway to optimize the red-white aesthetics, only the incisal shortening and thus the adjustment of the different crown lengths is necessary in order to be able to maintain the aesthetic vertical tooth height. The symmetry is checked again using dental floss.
laughing bow
The connecting line of the incisal edges of the maxillary teeth should run parallel to the lower lip in a convex curve. A straight or concave laughing bow is subconsciously perceived as strict or even unsympathetic.
Buccal Corridor
This is the lateral negative space between the side teeth and the corner of the mouth when smiling and depends on the shape and width of the upper dental arch. In the present patient case, the buccal corridor is in the 2nd/3rd quadrants significantly larger. Consequently, the information is transmitted to the dental technician that the teeth in the 1st/4th Quadrants have to be made more delicate and less bulbous in order to create an even overall picture. The smile also depends to a large extent on the teeth and their harmonious integration. The aesthetically relevant dental parameters include the size, shape, color and alignment of the teeth. As mentioned above, the average vertical height of the maxillary central incisor is 10.6 mm in males and 9.8 mm in females. It should also be noted that the shape of the teeth fits into the overall visual appearance of the patient and underlines their character. For example, B. rectangular, straight teeth a strong choleric to an aggressive appearance. The choice of the tooth shape therefore depends on the one hand on the appearance and on the other on the individual expectations and intentions of the patient. The color selection should also be made with the patient, since the same applies here: Beauty is in the eye of the beholder.
What is often forgotten are the characteristics of the teeth. The angle feature means that the occlusal surface or incisal edge transitions to the approximate surface at a more acute angle mesially compared to distally. The curvature feature makes it clear that the vestibular tooth surface has a greater curvature mesially than distally. You should pay attention to these parameters when inserting the temporary, otherwise an aesthetically perfect result cannot be achieved.
Step 3: Dissection and Visualization
Before the preparation, a treatment plan is made based on the photos and the dental technician converts the information into a wax-up. With the help of a silicone key, this aesthetically optimized version can be transferred intraorally as a mock-up after preparation. The patient can now express points that bother him or that he had imagined differently. The changes are then made directly on the chair. If the patient is satisfied with the result, an alginate impression is taken from this final situation to provide the technician with all the information that can then be used to fabricate the definitive restoration. Three to four weeks elapse between the incorporation of the temporary and the fabrication of the final restoration.
Step 4: Placement of the restoration
If you take all these parameters into account, you not only get an aesthetically optimal result, but also an extremely satisfied patient. When inserting the final restoration, you can be sure that he is satisfied with the aesthetics, since he was able to test the situation temporarily. The provisional test phase plays a very important role, especially in aesthetically demanding cases where the restoration is made with lithium disilicate. Since the crowns cannot be used temporarily, the dentist and the patient must be sure that the final situation will meet expectations.
Conclusion
In summary, it can be said that the goal is not perfection, but symmetry and harmony. This can only be achieved individually through the cooperation of the dentist, dental technician and patient. Many planning parameters can be used to simplify the intraoral transfer and ensure the best possible aesthetic result. However, these components should not be viewed too rigidly, but merely as guidelines to aid in treatment, each of which then requires patient-dependent adjustment.