Breaking the Cookie Cutter: Finding Our Way Back to Individuality with Shape, Form and Texture by Bill Marais, RDT

Losing our individuality
Years ago, my good friend Arian Deutsch, who is a tremendously talented removables technician, told me something profound. He said, "Cosmetic dentistry has hijacked individuality."

Those words have never rung as true and clear as they do today.

Our world is one of big business, global corporations and the vaporizing of the middle sector. Corporations' idea of accommodation is a one-size-fits-all mentality in which time and money are the only driving factors.

What happened to time spent on analyzing the individual's needs, personality and character? We are seeing the absolute loss of individuality in all sectors of our lives, and sadly, that includes the world of dentistry and dental technology.

But we don't have to let it happen, and we shouldn't.

Dentists make huge investments in CAD/CAM, where monolithic restorations are the common production units in dental offices and in production-line labs.

In dentistry, little thought is often given to patient education. Dental professionals are not striving to negate the media's warped portrayal of what makes a beautiful smile. Patients are not aware of what constitutes a natural smile.

CAD/CAM may be a necessity in the advancement of dentistry and dental technology, but I am also not opposed to monolithic restorations. We must, however, spend time on placing individuality and a human "fingerprint" on monolithic restorations and those created via CAD/CAM.

Dentists and dental technicians have to combine the human element with the machine. My friend Barry Brady, a fine-art photographer, once told me, "With technology at our hands, it has become too easy to make average work, and then mediocrity becomes the standard. We need to work against this not by trying to stop it, but by upping the quality and standard of our work."

Bringing back individuality
Here are several steps I take in my work every day to preserve individuality for patients while still striving for the highest standards (see Fig. 1).

In nature, there are no straight lines. I look at nature and I see the number 3: the apex, middle and base of the tree; the head, thorax and abdomen of insects. Or when it comes to human teeth, the cervical third, middle third and incisal third. Even the interproximal surface is divided into three segments, as is the incisal edge. Changing the lengths or positions of these segments changes the shape of the tooth (Fig. 2a).

How you position the mesial and distal line angles will also change the shape of the tooth. The three lobes on the facial surface of the tooth determine whether the surface is convex or concave. More importantly, natural teeth do not have a 100 percent flat, or a 100 percent round, facial surface.

The long axis of the central and lateral incisors must run more or less parallel (Fig. 2b). A common mistake made today is keeping the long axis of the canine running parallel with the adjacent incisors. The long axis of the premolars will more or less run parallel to the canines.

Far too little attention is given to the shaping of the lingual surfaces of the teeth. Curvatures on the lingual (Fig. 3) give rise to curvatures on the facial (Fig. 4). The purple arrows in the second figure indicate the curvatures and embrasures created by the indentations and curvatures on the lingual (red arrows in Fig. 3).

I greatly appreciate the adequate prepping of lingual surfaces. This allows me the space to properly create my lingual, and then facial, surfaces.

A common error in creating natural smiles is ignoring the importance of incisal embrasures. The spaces created by the openings of the incisal embrasures follow somewhat of a Fibonacci sequence up to the first premolar (Fig. 5).

Accurate impressions with tissue detail are vital for creating correct emergence profiles. In Fig. 6a, the emergence profile is incorrect. The tissue can be read in Fig. 6c, ensuring that the teeth emerge out from the tissues, as in Fig. 6b.

When replicating natural dentition, surface texture should not be neglected. It is important to keep in mind that a smooth surface, which is unnatural, results in specular reflection.

A rough surface texture causes diffused reflection. Keeping in mind that if natural teeth have a rough surface causing diffused reflection of light, clinicians should then ensure that restorations include surface texture that mimics the natural tooth, too. (Figs. 7a, 7b).



















Conclusion
Remember the rule of threes and pay close attention to your embrasures and line angles. The final restorations that you deliver should match the patient receiving them, not some computer algorithm. While a talented technician is not always an option, or the latest technology has altered your needs for a technician, this is not an excuse to ignore the basic elements of natural smile design outlined here.

In today's technologically advanced world, too many technicians are bypassing the basics—the foundation of individualized and quality work. By the "basics," I mean the following:

• We absolutely need to have 10,000 to 15,000 hours of blood, sweat and tears at the bench.
• Mistakes are inevitable—but we need to put in the hours to resolve technical and artistic issues.
• From Day 1 at the bench, we need to start performing art—we must add the human element of creativity and imagination.

If we remember and follow these basics in dental technology and dentistry as a whole, we will find our way back to individuality. After all, what is the difference between my work and 100% automated CAD work? It is detail and my fingerprint—individuality.



Bill Marais is trained and has extensive experience in all aspects of dental technology, including crowns and bridges, neuromuscular dentistry, dentures, neuromuscular dentures and implants. He received his bachelor's degree in prosthetic science in Cape Town, South Africa. Marais is also a key opinion leader for GC America.