Gone are the days when you could simply pick up your
high-speed and begin breaking enamel rods. Even though you
might have tested every muscle of the stomatognathic system, deprogrammed
for three weeks, are sure of the seating and health of the
condyles and have evaluated every tracing and diagnostic tool available.
If you and your patient have not participated in an active co-diagnosis
of your patient's perceived aesthetic disharmonies, and if you and your
patient have not agreed on a plan to address each of the perceived aesthetic
disharmonies, then don't touch that high-speed!
Every dentist thinks he/she is a cosmetic dentist. Patients think they
are cosmetic dentists as well. As dentists, we all have our mentors and we
feel we are well-educated about delivering cosmetic dental care. We know all
of the technical jargon. We have all of the gadgets and we know all of the
materials and how to use them.
Our patients on the other hand, have access to fan magazines, Marie
Claire, Cosmo, People and a host of other magazines that feature covers
showing "stars" with big, wide, white smiles. Every television personality has a
wide, white, straight smile. The weather girl, the anchor, the traffic person, not
to mention everyone on the celebrity gossip stations have wide, white smiles; they're
everywhere. Our patients want these smiles. Not necessarily naturally beautiful
smiles, but bold, attractive smiles. Smiles that say "I'm attractive, I'm healthy, I'm fun,
pick me!" Patients look at these smiles and compare them to their own. Your patient
might have a different perception of cosmetic dentistry than the vision you have in mind
for them. They know what they like... they don't want to hear why you can't do it for them.
Often, the only difference between a happy patient and one who is unhappy with your
treatment is simply communication. A great final result always begins with quality diagnostic photographs of the patient's smile
and full face, mounted study casts,
radiographs and a complete exam of
all hard and soft tissues.
Next, a co-diagnosis appointment is
set up with the patient, using the pretreatment
digital images in a visually
motivational and educational PowerPoint
presentation. This co-diagnosis appointment
is designed to help you to understand
what your patient does not like about his
smile. This appointment is not about you
telling your patient what you perceive as his cosmetic
needs. This appointment involves you really
listening to the concerns of your patient, understanding
the concerns, and agreeing on a plan to address the
concerns. Just make sure that you are not giving your patient
a Chevy Corvette just because you like it, when what your
patient really wants and expects is a Chevy Tahoe.
End this presentation with a number of before and after images
of cases just like the type your patient presents. Use your patients
mounted study casts as a reference during the presentation. This is
a powerful case presentation and should end up with the patient
letting you know what result he expects from your treatment.
After you completely understand what the patient does not like
about his smile, and after you and the patient have agreed to a plan
that will address each of his concerns, it is time to have your dental
lab create a diagnostic wax-up that addresses each concern you and
your patient have agreed to correct. If, on the other hand, you feel
for some reason you cannot adequately address the aesthetic concerns
of your patient, or if you do not feel comfortable performing
the types of treatment the patient has requested, now is the time to
suggest that he consult with another dentist for his care.
The diagnostic wax-up is the workhorse of the smile-makeover
dental practice. However, the diagnostic wax-up is only as good as
your diagnostic skills. It is your job to list all of the aesthetic disharmonies
that you and your patient would like to correct and help
your lab to create corrections in the diagnostic wax-up that satisfy
your patients concerns. Your dental lab can create a tooth-reduction
guide from your diagnostic wax-up that will aid you in minimal
preparation of your patient's teeth. Your dental lab can also create a
Siltek putty stent to help you create a composite mock-up directly
on your patient's teeth, should you prefer this method of toothreduction
guidance. Either way, the diagnostic wax-up is your road
map from your patient's pre-treatment condition to the final
restorations. Take advantage of this highly effective tool.
I have developed the following guide to help you diagnose your
patient's aesthetic disharmonies. Use this guide to help you identify
aesthetic disharmonies while viewing your digital images and evaluating
the study casts. The aesthetic disharmonies checklist you
develop with your patient will be the basis used to communicate
your aesthetic concerns to your dental laboratory.
Even though it has been said that "beauty is in the eye of the
beholder," there are definitely many repeating elements that a
large majority of lay people find attractive in a smile. The Aesthetic
Disharmonies Checklist will focus on these elements. The purpose
of the checklist is to help you to find departures from the "ideal
smile," often referred to as "visual tension." Remember, you might
not agree with every concern your patient mentions, but you must
keep an open mind and listen. Your goal is to try to understand
your patient's concerns regarding the appearance of his smile.
Aesthetic Disharmonies Checklist
1. Tooth Form Disharmonies
2. Tooth Color Disharmonies
- Height of the Central Incisors (Fig. 1)
The average height of a central incisor in an attractive smile
is about 10.5-11.5mm. The farther you move away from this
pleasing height, the more attention will be drawn to the central
Hint: Use a mm gauge and measure the height of the central
incisors. Should be 10.5-11.5mm to look right.
- Height to Width Ratio (Fig. 2)
The most visually pleasing proportions for a central incisor
are near 75 percent. The farther you move away from this
naturally pleasing proportion, the more attention is attracted
to the central incisors.
Hint: Measure the height of the central incisor, then
measure the width of the central incisor. Divide the width
by the height, the closer to 75 percent, the more pleasing
- Balance and Symmetry (Fig. 3)
In a pleasing smile, the central incisors should be mirror
images of each other. The lateral incisors can be slightly different
in shape for characterization, but not enough to draw
attention to the differences.
Hint: Check to see if the right side of the smile looks like a
mirror image of the left side of the smile. If not, this could be
a point of visual tension - a disharmony.
3. Tooth Position Disharmonies
- Discolored Teeth (Fig. 4)
Teeth that are very transparent or teeth with tetracycline
stains are classic examples of unattractive smiles. Teeth that
have had traumatic injury are often darker than other teeth
in the arch.
- Alloy Bleed Through (Fig. 5)
Dark gray and blue stains in the enamel of teeth in the aesthetic
zone are a turn off for patients with aesthetic concerns.
- Restorations Done One at a Time (Fig. 6)
No matter how great your dental lab technician might be, it
is very difficult (read impossible) to do cosmetic dentistry
"one tooth at a time."
Hint: To diagnose tooth color disharmonies, first look at the
smile as a whole. Are all of the teeth a similar color? Are they
too dark? Is there a patchwork of color? Is your eye attracted
to failing restorative dentistry?
4. Soft Tissue Disharmonies
- Midline Shift (Fig. 7)
Although the midline does
not have to be directly in the
middle of the face, the closer
it is the better. Often, loss of
a tooth in the aesthetic zone
will cause a midline to shift.
Hint: Look at the face
directly from the front. Is the
midline of the maxillary
teeth in the middle of the
face? Has it shifted or is it on
- Arch Form Collapse (Fig. 8)
Any time a tooth has been lost in the aesthetic zone, the arch
form has been compromised. Anterior crowding is also a
source of arch form collapse and loss of arch length. Collapse
of the bicuspids, such as in a mouth breather, is also a source
of dental arch form collapse.
Hint: Look for missing teeth or crowding in the aesthetic zone.
Look for deficient buccal corridor width. If it looks like an orthodontist
would have to expand the arch form to make room for all
of the teeth, this is an arch form collapse case.
- Anterior Crowding (Fig. 9)
Tooth overlap and anterior crowding is a real source of dental
arch form collapse and loss of arch length.
Hint: Crowded teeth might mask a collapsed arch form and
lost arch length. Check the buccal corridors for dark spaces. Also,
if you feel an orthodontist would have to expand this arch form to
replace all of the teeth into the archform, you are looking at a collapsed
- Excess Space (Fig. 10)
The contact arch form is the ideal in cosmetic dentistry. Any
spaces in the aesthetic zone are considered "bad juju".
Hint: One of the easiest cases to diagnose and the quite possibly
most difficult to treat might be the case with small teeth
and large arch form. If an orthodontist would have to move
the teeth closer together to create a contact arch form, you
have too much space.
5. Failing Restorative Dentistry Disharmonies
- Gingival Height and
Symmetry (Fig. 11)
The height and form
of the gingival margins
can really enhance the
appearance of teeth in the aesthetic zone. The gingival heights of adjacent teeth
should appear to flow. Deviations from "flow" create a "visual
disharmony" and catch your attention.
Hint: Ideally, the gingival height is at the same level as the
lip outline during a full smile. The lips "frame" the teeth and
do not show an excessive display of soft tissue. The gingival
height should be like a mirror image from one side of the
mouth to the other.
- Gingival Embrasure Form (Fig.12)
Gingival embrasures should be of a uniform size and shape.
Departures from uniformity are easily noticeable in the aesthetic
Hint: The ideal gingival embrasure forms start at about 50
percent of the height of the central incisors and proceed to
get progressively shorter with each tooth proceeding distally.
- Gingival Zenith Placement (Fig. 13)
Hint: Loss of anterior teeth or crowding of the anterior teeth
will always result in the migration of the gingival zeniths
toward the midline. Any attempts to restore this case with
crowns or veneers without moving the gingival zeniths
distally will result in restorations that do not exhibit ideal
proportions. The restorations will appear very tall and slim.
This is visual tension.
- The gingival zenith gives the illusion of where the tooth
is actually located within the gingiva. Gingival zenith
placement in the aesthetic zone is critical to create a natural
- When dealing with a collapsed arch form due to loss of
teeth, small teeth and/or crowded anterior teeth, the gingival
zeniths have migrated toward the midline. In order
to restore this type of smile, you need to use a diode laser
to move the gingival zeniths distally to where the teeth
were prior to the crowding or loss of teeth.
- Failing Crowns/Veneers/Natural Teeth (Fig.14)
After years of service, many restored smiles need to be
"freshened up." The natural teeth around crowns and
ceramic veneers might become worn, or they might darken,
or they might break, necessitating repair and/or replacement
of existing crowns and/or veneers.
- Failing Composites/Alloys (Fig. 15)
Dental restorative composite has a finite lifetime in the
mouth. Over time these restorations discolor, chip, wear and
generally show the effects of the aging process. Dental alloy can leave dark gray and/or blue stains in the natural tooth
enamel. These failing restorations are unsightly, and are a
source of visual tension.
- Exposed Margins (Fig. 16)
As the aging process continues, gingival tissue might
move apically, exposing unsightly metal or ceramic margins.
Although these teeth might not exhibit any decay,
they are not usually very well tolerated by aesthetic-conscious
- Failure to Address the Patients Cosmetic Concerns (Fig. 17)
Some restorative dentistry just does not please the patient.
In this case, if the patient has legitimate concerns, the only
way to proceed is to remake the case, being careful to address
the patient's cosmetic concerns.
Hint: Look at the patient's smile and teeth. What catches
your eye? What does not appear right? Do you see a patchwork
of colors? Do you see exposed restoration margins?
Do you see issues with tooth proportions or gingival zenith
placement? Would you be able to address the aesthetic
issues that concern the patient?
If you are planning to do more smile makeover dentistry or if
your practice does a large number of full-mouth reconstructions,
this checklist will help you ensure both you and your patient have
evaluated all of the aesthetic concerns and have agreed on a plan
to address those concerns.