Dentofacial esthetics/ orthodontic teeth

DENTOFACIAL ESTHETICS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

1 INTRODUCTION
2 DEFINITION
3 HISTORICAL PERSPECTIVES
4 ARTISTIC PRINCIPLES AND VARIOUS
GUIDE LINES
5 FACTORS OF ESTHETIC
DENTOFACIAL COMPOSITION AND THEIR
CLINICAL SIGNIFECANCE

ILLUSION BIOLOGY OF ESTHETICS
UNDERSTANDING THE COLOR
ESTHETICS IN COMPLETE DENTURE
ESTHETICS IN FIXED PARTIAL
DENTURE
ESTHETICS IN IMPLANT DENTISTRY
CONCLUSION

Webster’s Third New International
Dictionary defines “esthetic” as
appreciative of responsive to, or
zealous about the beautiful: having a
sense of beauty or fine culture.”

GPT: 1. The branch of philosophy dealing
with beauty
2. “The theory and philosophy
that deal with beauty and beautiful,
especially with respect to the appearance
of a dental restoration, achieved through
its form and /or color

HISTORY
In the EL Gigel cemetery located in the
vicinity of the great Egyptian pyramids, two
molars encircled with gold wire were
found. This was apparently a prosthetic
device.
In the Talmudic law of the Hebrews, tooth
replacement permitted for women.

The Etrascans were well versed in the use
of human teeth or tooth carried from
animals to restore missing dentition.

The dentolabial smile, where the teeth are
seen behind the lips, starts to emerge In
the first decades of 20th century

The ancient Japanese proudly displayed
black teeth
The Mayans flashed a jadeite studded
smile testify to an apparently deep seated
urge decorate the body.
Today, dental esthetic is founded on a
more esthetically sound basis the general
improvement of dental health.

The esthetic principles and various
scientific guidelines that is
elementary for the study of
dentofacial esthetic.
Physical attributes of the elements of the
dentofacial composition.
Factors of esthetic dentofacial
composition and their significance.

Physical attributes of the elements of the
dento-facial composition
CONTRAST
UNITY OF ONENESS
SYMMETRY
PROPORTION
GOLDEN PROPORTION

HORMONY
DOMINANCE
BALANCE

Factors of esthetic dento-facial composition
and their clinical significance
1 REFERENCES
2 SMILE ELEMENTS
3 DYNESTHETICS
4 BUCCAL CORRIDOR
5 BIOLOGY OF ESTHETICS

6 DISRUPTIONOF DENTOALVEOLAR
ELEMENTS
7 BIOLOGY OF LIP AND FACE CONTOURS
8 DENTAL ARCH FORM
9 INCLINATION OF LABIAL SURFACES OF
TOOTH CONTOURS
10 VERTICAL DIMENSION OF FACE HEIGHT
11 ESTHETIC OF ADULT DEVELOPMENT AND
AGING

CONTRAST
It is that factor which makes the various
elements of a composition visible. The eye
can differentiate the part of an object due
to contrast of color, lines, patterns,
textures etc

UNITY OR ONENESS
“It gives different parts of the composition
the effect of a whole.”Unity can either be
static, when repeated shapes or designs
are seen as in inanimate things, like the
composition of crystals or dynamic and
changing as in living beings.

COHESIVE AND SEGREGATIVE FORCES
Any element which tends to unity a
composition is a cohesive force.
Segregative forces are those elements
which break the monotony of the
composition

SYMMETRY
It is the regularity of arrangement of forms
either from left to right as in horizontal
symmetry or from a central point to either
side like a mirror image as in radiating
symmetry.
The horizontal symmetry looks dynamic
respective and uninteresting which the
radiating symmetry looks dynamic and
interesting.

PROPORTION
To be able to give a certain mathematical
representations of beauty for numerically
expressing the relationship of the various
units that combine to make a composition,
the term proportion is used.

In a dento-facial composition a golden
proportion exists between the maxillary
teeth antero-posteriorly.

Given its name by Pacioli a mentor of
Leonardo Da Vinci, this phenomenon has
unique properties and it battles the
imagination and eludes understanding.
The proportion is 1.0 to 1.618. This
relationship links geometry to
mathematics, hence it has also been
called the “sacred geometry,” the magic
numbers,” and “the golden cut”.

In the case of teeth, the lower central incisor
may be used as a starting reference.
Interesting the upper central incisor has a
golden phi or 1.618 proportion to the lower
incisor and the total width of both lower
controls are golden that of the upper
incisors.

GOLDEN PROPORTION:
A central incisor is considered perfectly
proportionate when the maximum width is
approximately 75% of the maximum length
(of clinical crown) this is the ideal width to
length ratio

DOMINANCE
It exists when a strong centralized
structure is surrounded by well
documented, characterized structures

BALANCE
It is achieved when there is an exact
equilibrium between the forces presents
an either side of the fulcrum in a
composition. In dentistry this implies the
balance of the elements in relation to the
midline.

REFERENCES
HORIZONTAL
inter pupillary line
The comissural line

The interpupillary line helps to evaluate
the orientation of the mesial plane the
gingival margins and the maxilla.
An imaginary horizontal line
through the incisal plane and the gingival
margins should be visibly parallel to the
interpupillary line.

VERTICAL LINE REFERENCES
The facial midline serves to evaluate the
location and axis of the dental midline and
the mediolateral discrepancies in the tooth
position

SAGITTAL REFERENCES
Soft tissues analysis at a standardized
position left in studying the profile of an
individual.The contours of the upper and
lower lips and lip support is determined by
the position of the anterior teeth.

PHONETICS REFERENCES
Phonetics play a part in determing maxillary
central incisor design and position ‘F’ and ‘V’ are
used to determine the tilt of the incisal third of
the maxillary central incisors and their length.
The ‘M’ sound is used to achieve a relaxed rest
position and if repeated at slow intervals can
help evaluate and the incisal display at rest
position.

‘S’ or ‘Z’ sounds determine the vertical
dimension of speech. Its pronunciation
makes the maxillary and the mandibular
anterior teeth come in near contact and
determine the anterior speaking space

Smile can be classified as Passive, active
and laugh.
Passive Smile: In passive smile the lips are
parted slightly away from the rest position
expressing content passion, desire,
surprise etc.

Active Smile: In active smile the lips move to a
significant extent away from the rest position
displaying more tooth and even gums,
expressing joy, welcome, happiness etc.
Laugh: Laugh is an instant fluctuation from an
active smile position where the facial muscles
instantly act leading to a maximum exposure of
the teeth and gums. Humorous and funny
situations usually lead to such an expression

LIP AND LIP LINE:
The length the curvature and the shapes
of the lips significantly influence the
amount of tooth exposure during rest and
in function.

UPPER LIP LINE:
Upper lip line helps evaluate the length of
the maxillary incisor exposed at rest and
during smile and the vertical position of the
gingival margins during smile

LOWER LIP LINE
Lower lip line helps to evaluate the
buccolingual position of the mesial edge of
maxillary incisors and the curvature of the
incisal plane.

SMILE LINE:
It is an imaginary line passing through the
incisal edge of the upper anterior teeth.
The smile line usually coincides or runs
parallel to the inner vermilion border of the
lower lip.

NEGATIVE SPACE
Negative Space is a dark space appearing
between the Jaws and the mouth opening
either at the corner of the mouth or around
the buccal aspect of the posterior teeth
during active smile

SMILE DOMINANCE Different facial
features stand out differently in the eyes of
every be holder. In certain cases the most
predominantly striking features of a face is
the smile these are the ‘Dominant Smile’

DYNESTHETICS
The dentogenic concept and dynesthetics must
be given favorable consideration.
This concept is a very useful guideline in the
selection of artificial teeth.
Fisher states, “We utilize the
approach of the artist when we analyze the
patient first as to sex, that is male or female;
then as to age young middle aged or old.

Buccal corridor
The shape and position of the dental arch
determines the size of the buccal corridor.
The buccal corridor is the space between
the buccal surface of the upper teeth and
the corners of the mouth visible when the
patient smiles

DISRUPTION OF THE DENTAL –ALVEOLAR
ELEMENTS
The structural and spatial elements are
significant in diagnosis, treatment planning
and reconstruction of esthetics are multiple.
They are :
The height and inclination of the plane of
occlusion
The arch from contours of the maxilla and
mandible and their relationship in the static
and dynamic state.

The overjet and overbite in the static and
dynamic states.
The individual tooth position in the arch
with respect to the coronal and root
inclination relative to the vertical plane
The inter cuspal relationship with respect
to centric relation, centric occlusion
protrusive and other excursive positions.

THE IMPORTANT ELEMENT EFFECTING
ESTHETICS.
The biology of lip and face contours and
profile.
The dental arch form.
The inclination of the labial surface of tooth
contours.
The vertical dimension of facial height.
The esthetic of adult development and aging.

ILLUSION
Creating esthetic restoration through
special effects.
Creating illusions one of the most
important objectives of esthetic dentistry.
The ability to make a tooth wider or
thinner, smaller or larger is a invaluable
aid when solving difficult esthetic
problems.

Principles of Illusions
Principles of illusion such as those used to
describe form light, and line may be
applied specifically to dentistry.
In the presence of excess light or in the
absence of light, form cannot be
distinguished since shadows are
necessary to help make perceptible the
contour or curvature of surface and depth

Illusion in dentistry are created using
three techniques
Shaping and contouring
Arrangement of teeth
Staining

Color can also be used to increase the
illusion of width.
For instance when a body color is selected
that is slightly lighter than that of the
adjacent teeth the narrow tooth will more
prominent and therefore wider

Techniques for various problems.
The most commonly encountered problems that
can be corrected through illusion are discussed
below.
Space available is wider than the ideal
Replacement tooth
Shaping
The width of the replacement tooth or teeth will
have to wider then ideal, therefore various
illusions achieved through shaping and
contouring should be used. The Width needed to
close the space is gained in the areas of contact.

The too short tooth
If a tooth appears too short, as is likely if it
is wider than normal, several techniques
can be used to create the illusion of
length.
If the gingival third is narrowed
mesiodistally the tooth will appear more
taped and longer

The too long tooth
When alveolar or gingival recession has
been severe, the length of pontics or
crowns must be made to appear shorter.
Basically vertical groves or lines should be
diminished and horizontal lines
emphasized

Incorporating the personality of the
patient
A delicate personality can be differentiated
from the vigorous one by the degree of
characterization, coloring and
arrangement of teeth.

INCORPORATING SEX CHARACTERISTIC
When teeth are contoured crowns or carved, we
may need to incorporate either feminine or
masculine characteristic
To interpret a female mouth as one where the
contours and lines are more rounded and curved
than those in the male, which are usually flatter,
sharper , and more angular.

By rounding angels and edges, a more
feminine appearance can be achieved.
By squaring angles and edges, a more
masculine feeling is created.
The idea of masculity can be further
enhanced by slightly abrading the incisal
surface

Aging wears down the incisors
Increasing the internicisal distance by
making the centrals again longer than the
laterals can help make the individual
appear younger.

REDUCING AGE EFFECTS ON THE
SMILE
Many patients are motivated to seek esthetic
dental treatment to make them look
younger.
This is usually possible by the use of
various restorative techniques.

Incorporating Age characteristics
Once the correct form and function have
been achieved in a crown
The wear and stains that
normally accumulate with age should be
incorporated into the new restorations to
blend with the appearance of the
remaining natural teeth

ARRANGEMENT
The most direct solution for inadequate space is
to rotate and overlap the replacement crowns or
teeth without reducing their ideal widths.
If rotation and overlap is
unacceptable or impossible, and if the
encroachment upon the space has been severe,
it may be possible to eliminate one tooth entirely
with good results

COLOR
The three dimensions of color
Evaluating color differences
Dental shade guide lines
Shade selection
Shade modification
A look to the future

The three dimensions of color:
E Brace Clark an early leader in color
matching in dentist stated the need for
learning the three dimensional nature of
color.

Hue:
The dimension of hue is most easily
understood. It is in Munsell’s words, that
quality by which we distinguish one color
family from another, as red from blue to
purple.

VALUE
Value relates color brightness to the
specific area on the black-while scale. The
value of a color is determined by that
quality of gray with which its brightness
can be matched

CHROMA
Chroma, third dimension, was described
by Munsell as that quality which
distinguishes a strong color from a weak
one

Perception of color
The eye: Under low lighting conditions, only
rods are used .
These receptors allow an interpretation of the
brightness of objects to be made.
They are most sensitive to blue-green objects.
Color vision is dependent on the cones, which
are active under higher lighting conditions.

Color adaptation: Color vision decreases
rapidly as an object is observed. The
original color appears to becomes less
and less saturated until it appears to less
almost gray.

Deceptive color perception: The brain can be
tricked in how it perceives color.
The color of teeth can also look different if the
patient is wearing brightly colored clothing or
lipstick.
.
Fluorescence: Fluorescent materials, such as
tooth enamel, re-emit radiant energy at a lower
frequency than it is absorbed.

Metamerism: Two colors that appear to be
a match under a given lighting condition
but have different spectral reflectance are
called metamers, and the phenomenon is
known as metamerism. The problem of
metamerism can be avoided by selecting a
shade and confirming it under different
lighting conditions

Opalescence: Natural teeth, particularly at their
incisal edge, exhibit a light-scattering effect that
creates the appearance of bluish-white colors as
the teeth are seen at different angles.
Color blindness: Defect in color vision effect
about 8% of the male population and less of the
female population. Different types exist, such as
achromatism, dischromatism, and anomalous
trichromatism.

Vitapan 3D Master Shade
guide
The manufacturer of this
recently introduced shade
system claims that it covers
the entire tooth color space.
The shade samples are
grouped in six lightness levels,
each of which has chroma and
hue variations in evenly
spaced steps.

Currently available devices
Shade eye: Manufactured by
Shofu Dental Corporation. It is a
colorimeter.
Easy Shade: Manufactured by
Vident. It is a spectrometer.
Shade Scan: Manufactured
Cynorad. It is a digital color
imaging/colorimeter.

Shade vision: Manufactured by
X-Rite Inc. It is a Digital color
imaging/colorimeter.
Spectro shade: Manufactured
by MHT, Niedederhasli. It is a
digital color
imaging/spectrometer.
Clear Match: Manufactured by
smart technology. Software to
be used with digital camera

ESTHETIC IN COMPLETE DENTURES
Tooth selection
Tooth selection involves choices of shade, size
and shape of the artificial teeth.
Tooth shade
Historically shade selection was based on the
patients’ hair and eye color, complexion and
age.
Fursh and Fisher introduced the dentogenic
concept for establishing esthetics.

Tooth Size
Generally men have larger teeth than women.
There are two popular methods to select the
appropriately size of the maxillary teeth.
The first is to base the selection on the space
available for the placement of teeth.
The second is based as the facial and tooth size
proportion

Tooth form
Berry probably was first to demonstrate the
correlation between the outlined of maxillary
incisor and the inverted outline form of the face.
J Leon William’s classified facial form as
square, tapering, square-tapering and ovoid.
House and Loop proposed 3 typical forms
Square
Tapering
Ovoid

And six other combination forms
Square tapering
Reverse tapering
Ovoid square
Ovoid tapering
Ovoid reverse tapering
Square tapering

GUIDELINES FOR TOOTH PLACEMENT AND
ARRANGEMENT
FRONTAL VIEW: (ANTERIOR TEETH)
Anterior teeth parallel to interpupillary line.
Incisal edge of maxillary incisors 1-2mm below
maxillary lip at rest.
No bulging should be evident under the nostrils
Philtrum should be restored.
Full vermillion border of lip should seen.
Smile line should follow the line of the lower lip in
smiling.,

Saggital view
Upper lip should be averted and not fallen
Tooth support of the lip is by 2/3 of the
incisal labial surface of the anteriors.

Horizontal view:
Central incisor should be 8-10mm anterior
to the midpoint of the incisive papillae.
Canines are on a line drawn perpendicular
to the middle of the palate, through the
center of the incisive papilla.

Characterization
Lombardi felt that the central incisors
make the best statement of the patient’s
ages whereas lateral incisors note
patient’s sex and canines reflect patients’
vigor.

ESTHETICS OF FIXED PROSTHODONTICS
Diagnosis and treatment planning of esthetic
problems
.
Orthodontic considerations: Because
alignment of anterior teeth is an important
aspect of dental aesthetics, orthodontics has
traditionally been intimately involved in esthetic
dentistry

VERTICAL TOOTH POSITION:
We must assess the position of the maxillary
incisors relative to other facial landmarks.
From an orthodontic perspective, two major
landmarks are critical to the analysis.
The first is the level of the lip when the patient
is smiling, and the second is the interpupillary
line.

INTERPUPILLARY LINE: If the incisal
plane of the maxillary anterior teeth does
not coincide with the interpupillary line
orthodontic planning depends on the inter
relationship of four factors: incisal plane
posterior occlusal plane, inter pupillary line
and crown length.

Upper lip line: When patients smiles, the upper lip
should expose the entire crown of the central
incisors.
some patients show excessive amounts of
gingiva when they smile which may be
unaesthetic.
The orthodontic movement can be accomplished
intracoronally with an intrusive force to the
incisors, or extra orally using a head gear to
place the maxillary incisor superiorly.

MEDIOLATERAL POSITION:
The mediolateral position of the maxillary central
incisors is important aspect of esthetics.
In some situations the maxillary dental midline will
deviate to one side.
When correcting these situations it is important to
distinguish between the true midline deviation
and improperly inclined incisors.

CROWN LENGTH:
Assessment of crown length discrepancies is
important in order to determine proper treatment
become several options exist for correcting
crown length discrepancies.
CROWN WIDTH: An important but often
overlooked aspect of maxillary anterior
aesthetes is crown width, orthodontist often treat
patients with disproportionate width of anterior
teeth.

RESTORATIVE DENTISTRY CONSIDERATION
Bleaching, composite resin bonding cosmetic
contouring and porcelain laminate veneers used
singly or various combinations provide
conservative solutions or economic alternatives
for numerous esthetic problems that would
conventionally have required extensive crown
preparation.
.

DIRECT COMPOSITE RESIN BONDING:
The main advantages of direct composite
resin bonding are to obtain an immediate
esthetic result and patient satisfaction in
one of two office visits, conservatively and
relatively low cost.

PORCELAIN LAMINATE VENEERS:
This minimally invasive procedure results in
limited pulp and periodontal involvement
because tooth preparation is mostly
contained to the enamel and relies on
supraginigval margins.

Full coverage crowns
Metal ceramic crows: Mechanical strength
durability, simplicity and excellent esthetic
potential are traditionally associated with
metal ceramic restorations.
To achieve a proper shade, tooth reduction
may have to be invasive and result in pulp
trauma or dictate elective endodontic
therapy.

ALL CERAMIC CROWNS.
For maximum predictability, all ceramic crowns
are presently best suited for maxillary incisors
with proper indication, in addition their
mechanical properties may be enhanced with
resin luting cements.
E.g.: Aluminous porcelain jacket crown.
Hi-ceram, Dicor, Optec H.S.P.
In-ceram, Allceram
Dicor, Foil crowns

ESTHETIC IN IMPLANT DENTISTRY
.
The requirements for optimizing good esthetics:
. Bone quantity: This is the defining factor for deal
positioning of the implant.
Bone augmentation procedures: Especially on the
anterior of maxilla to give adequate support for implants.
Soft tissue management for esthetics: One of the most
satisfactory and simple procedures performed to
optimize esthetics is to guide the gingival tissue to form
the interdental or interimplantar gingival papilla

ADVANCED MATERIAL IN DENTOFACIAL ESTHETICS:
Polymer ceramic: The products in this new category of
restorative materials have improved properties of
previous Bis GMA, urethane, or polycarbonate based
resin composite due to advances in matrix chemical
bonding
The other terms used to describe these products include
are
(1) Polymer glass ceramic
(2) Ceramic optimized polymer
(3) Ceromer

commercial products:
Art glass (Heraeus Kulzer)
Belle Glass HP (kerr/Sybron)
Hercuilite XRVT (Kerr VSA)

ADVANTAGES
wear is very close to that of natural teeth.
Improved color stability over conventional
composites is due to reduced water sorption.
The moduli of elasticity are quite similar to that
of dentin these materials can be bonded to
enamel and dentin for excellent retention and
seal. They are easily repaired intra orally than
porcelain.
From a laboratory perspective fabrications can
be done directly an working dies shrinkage is
minimal compared to porcelain

LASERS IN AESTHETIC DENTISTRY
Two separate issues appear vital for success when
performing aesthetic general dentistry, the first is
achieving adequate isolation of the operative site and
leaving the healthy tissue intact.
The other procedures by laser gingivectomy including
crown lengthening, ovate site creation, uncovering
implant and taking impressions gingival sculpting and
tissue management during bonding procedures.
The second point for cosmetic success is the
preservation of as much natural tooth structure as
possible and hard tissue laser offers this conservation
and structural integrity.

CONCLUSIONS:
With changing “concepts” the perception of
beauty there is an emergence of new definitions
to the parameters of judging aesthetics.
The changing trends in this field will reorient the art
element involved in esthetic dental creations but
its established scientific guidelines will always
provide the sound basis for this change.

Thank you
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Dentofacial esthetics/ orthodontic teeth

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