by Dr. Jason Olitsky
For the final installment of my 7 Violations of Smile Design series, I’ll explore how instituting
a knowledge of gum symmetry, papilla heights, and smile lines can maximize positive outcomes
in your esthetic cases. When evaluating the esthetic principles inherent to successful smile
design, there are 7 violations that are common and undermine the success of the finished
cosmetic case. Reviewing these commonalities and focusing on certain concepts such as
gum symmetry can help you avoid and correct areas of concern.
Overlooking Critical Positions
Proper treatment planning is where everything begins. This is the basis for successful smile design and it is where you should focus your attention.
Pro Tip #1: Properly evaluate the pink esthetics.
Should you overlook the gingival margin positions, you’re leaving yourself vulnerable to the consequences of a treatment plan that under- or completely fails to utilize the gingival margins.
Ideal Symmetry Principles:
- The gingival margins of the canines and central incisors should be symmetric and in a more apical position compared to the gingival margins of the lateral incisors.
- There should be a gradual incisal movement of the gingival margins toward the more posterior teeth.
- The maxillary canines and central incisors should be on the same plane and the laterals should be in a slightly incisal position to that line.
Pro Tip #2: The most important symmetry principle is to ensure that the gingival margins of the laterals fall short of the line drawn from the gingival apex of the centrals to the canines.
In smile design when are these principles more integral? The answer is when treating patients with medium to high smile lines. Elevate your knowledge with an understanding of the smile line. It is a labiodental dynamics principle that can be defined as the location of the lip when a person smiles.
What are the facts? 69% of people, when smiling, show 75% to 100% of their central incisors and inter proximal gingival papilla.How can you utilize this knowledge? It all has to do with conceptualizing the advantages of symmetry versus harmony.
Harmony v. Symmetry
Let’s get back to the basics.
Harmony: A recurring theme, such as having centrals or laterals of the same lengths.
Here’s where things get tricky and lean on the side of artistry, because the answer to whether you should emphasize symmetry or harmony in smile design might surprise you. From my experience, I can say that more emphasis should be placed on harmony over symmetry when designing a smile.
Symmetry: The mirror image of parts of components about the y-axis.
The key here is giving preferential treatment to balance and beauty over a form of unnatural symmetry.
Pro Tip #3: Restored tooth lengths to create symmetry can disrupt the harmony of the smile, especially when gingival margins lack symmetry.
There are a lot of moving parts to consider, but what it comes down to is the unintended result of the smile creating an unpleasant appearance. My approach emphasizes a holistic sense of esthetic principles.
Pro Tip #4: To resolve this issue and create harmony in the smile, ensure that tissue heights are evaluated in treatment planning.
Plan for Success
One of my favorite methods for evaluating a smile line is to begin with excellent pre-treatment photography.
Pro Tip #5: Gingival margins should always be evaluated with a picture/model that is properly oriented to resemble the patient’s horizontal position.
It really is all in the planning stages. Before you even being gingival contouring or hard tissue crown lengthening, go back to the drawing board and plan out gingival changes. Rely on information gathered from diagnostics, which can include sounding bone at various sites on each tooth.
Once again, you must emphasize planning. I cannot stress this enough. Without this crucial process, you may inadvertently create canted gingival margins or undesirable tissue heights.
Do not carry out surgical procedures without proper planning.
Pro Tip #6: Create surgical guides or templates for the teeth.
These planning tools assist you in controlling gingival changes during surgery.
What it comes down to is an open and honest relationship with the patient, who can be an integral partner in the initial processes.
One way to take advantage of this is to evaluate images of the patient’s teeth and smile with the patient before performing any restorative treatment. This will help them visualize areas in the gums that are not ideal and could result in compromised esthetics.
Pro Tip #7: Educate patients about their treatment prior to beginning treatment.
It may seem simple in hindsight, but in the end if you are not discussing compromises in a patient’s smile design with your patient, you will not be able to deal with any unrealistic expectations that they may have.
Check out the first six violations of smile design in the series, including “A Crooked Smile,” “The Reverse Smile,” “The Social Six,” “Four Central Incisors,” “Overcontoured Teeth,” and “Ignoring the Negative Space” to elevate your learning.