Diagnosing Aesthetic Disharmonies by Harry A. Long, DMD

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
  1. 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 incisors.
  2. Hint: Use a mm gauge and measure the height of the central incisors. Should be 10.5-11.5mm to look right.
  3. 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.
  4. 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 the appearance.
  5. 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.
  6. 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.
2. Tooth Color Disharmonies
  1. 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.
  2. 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.
  3. 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."
  4. 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?
3. Tooth Position Disharmonies
  1. 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.
  2. 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 an angle?
  3. 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.
  4. 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.
  5. 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 arch form.
  6. Excess Space (Fig. 10) The contact arch form is the ideal in cosmetic dentistry. Any spaces in the aesthetic zone are considered "bad juju".
  7. 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.
4. Soft Tissue Disharmonies
  1. 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.
  2. 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.
  3. Gingival Embrasure Form (Fig.12) Gingival embrasures should be of a uniform size and shape. Departures from uniformity are easily noticeable in the aesthetic zone.
    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.
  4. Gingival Zenith Placement (Fig. 13)
    1. 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 appearing smile.
    2. 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.
  5. 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.
5. Failing Restorative Dentistry Disharmonies
  1. 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.
  2. 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.
  3. 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
  4. 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.
  5. 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.

Author's Bio
Dr. Harry Long graduated from Fairleigh Dickinson University School of Dentistry. Since then he has completed thousands of hours of continuing education in all aspects of dentistry with a particular focus on patient care and aesthetic dentistry. He belongs to the American Academy of Cosmetic Dentistry, the New Jersey Dental Association, the Passaic County Dental Society and the American Dental Association. He is also a fellow of the Academy of General Dentistry.


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