7. Non Negotiables!!
Good oral health
Comprehensive assessment
Necessary radiographs
Study casts – mounted?
Photographs
Diagnostic wax up
Understand patient desires/expectations
Road Map
Diagnostic wax up
Diagnostic try in
Agree the goal of treatment – KNOW END POINT FIRST
Can we deliver?
8. Smile Diagnosis/Analysis
Determine patient‟s concerns and expectations
Evaluate what is present
Diagnose the problems
Treatment options
9. Use what we were taught for dentures
and morphology!!
1. Facial Reference
Lines
2. Dimensions &
Proportions
10. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry
13. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry
14. 2. Upper Lip Line
Evaluate:
Incisor length at rest
Men show on average 1.91mm tooth
when lip is at rest
Women show on average 3.4mm tooth
when the lip is at rest
Younger people show more (3.3mm)
than older people (1.26mm)
Vig and Brundo 1978
15. 2. Upper Lip Line
Evaluate:
Gingival marginal position during smile
Asymmetry
─ ─
─
─ ─ ─
16. 2. Upper Lip Line
Evaluate:
Gingival marginal position during smile
Asymmetry
“High lip line” “Low lip line”
17. „Gummy smile‟ or Vertical Maxillary Excess
How much is too much??
2-3mm good
>3mm ???
18. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry
20. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry
21. 4. Midline - Facial vs dental
Run perpendicular to the interpupillary line
Midline of central incisors coincides with midline of
face in 70% cases Miller et al. 1979
22. 4. Midline - Facial vs dental
Max and mandibular midlines do not match in
75% cases – not a problem
27. Tooth Dimensions & Proportions
Central tooth is DOMINANT tooth
Lateral is always smaller
28. Tooth proportions
Central is dominant tooth
Longer than it is wide
• 10.5-11.5mm long
• 8-9mm wide
• <6.5mm wide
( too skinny)
• > 9mm maximum
(too square)
29. Tooth proportions
Lateral is always smaller
2/3 width of the central
(Golden Proportion)
Canine
• 2/3 width of the lateral
30. Need to know the dimensions of teeth!!!
Proportion and Idealism
Optimum size of central incisor
Optimum size between central, lateral and canine
Symmetry
Perspective and Illusion
The art of camouflage
32. Symmetry
Good result Lateralise the canine
Asymmetry of arch Veneer the central-length
Hypoplasia of central Veneer the first premolar
Missing lateral incisor
33. Facial Reference Lines
1. Interpupillary line
2. Upper lip line
3. Lower lip line
4. Midline
5. Incisal Plane
Scientific Principles of Aesthetic Dentistry
35. Aesthetic risk assessment for
periodontal-plastic surgery
Aesthetic risk low medium high
factors
Medical status No med history Surgical risk
Periodontal Non susceptible Early onset P.D.
status thick tissue Thin tissue
Smoking habits Non smoker Less than Greater than
10 a day 10 a day
Patients Low Medium High
aesthetic
expectations
Lip line Low Medium High
47. Road Map
Decide end point first
Establish correct incisal length
Dominant centrals
Convex smile line
Check tooth anatomy –dimensions, proportions etc
How bright?
What Jaw position?
Diagnostic casts and wax ups?
Conveying this information to the patient
54. TIPS IN CROWN LENGTHENING FOR
AESTHETICS
Patient Expectations
Lip Smile Lines
Extent of The Aesthetic
Issues
Tissue Quality /
Condition
Biotype of the Tissues
Probability &
Predictability of
Achieving Success
Potential Complications
65. Post crown lengthening when to restore
with final restoration.
If bone removal is carried out a healing
period of six months prior to definitive
restoration is advised Pontoreiro &
Carnevale 2001
Recommended waiting 6 months after
osseous surgery before final restoration; the
gingival margin can continue to alter its
position even after 6 months Kois
69. Rules in aesthetics for implants
“The bone sets the tone but the tissue is the
issue”
Preserve the extraction socket
Remember basis surgical techniques
Overbulking with soft tissue
Tissue moulding
Temporary restoration
70. Preserve the extraction socket
Control marginal
inflammation
Control apical
infection
Minimal
disturbance of soft
tissue
Blood clot
85. Tooth Whitening - Routine Patients
2-6 weeks
Go to a B1 or A1
shade
Bleach for 2 hours
or whole night
86. Tooth Whitening - Smokers
1-3 months
Shade change is not
as predictable
87. „Inside outside‟ bleaching
CP in access cavity, Sealed or
patient inserted
Veneer may not need opaque
cement
Wait 2 weeks for full bond
strength
88. Tooth Whitening - Restorations
↓
Restorations do not change shade and may need to be
replaced
90. Safety of night guard bleaching (10% CP)
10 year recalls of 2-6 weeks nightly treatment
No root canals required
No external or internal resorption
No sensitivity outside normal limits
No detrimental effects on tooth structure
Ritter AV, Leonard RH, et al. 2002.
Leonard RH. 2003.
91. Higher concentrations of CP?
Greater chance of sensitivity
No better outcome
May be faster, but also less stable
92. How long does NGVB last with no touch-
up or re-treatment?
Ritter et al. 2002. Safety and Stability of NGVB: 9-12 years Post
Treatment. J Esthet Restor Dent
94. Recession?
make it longer, thicker, thinner, better?
Free Gingival Grafts (FGG)
Coronally Repositioned Flap (CRF)
Connective Tissue Graft (CTG)
Enamel Matrix Proteins (Emdogain)
Matrix ( Mucograft)
OR ALL THE ABOVE?
95. Free gingival graft
Do not restore area of recession
Advantages
Patients own tissue
Reduce cost
Disadvantages
Donor site
Technically difficult
Maybe adjunctive to other
procedures
96. Connective tissue graft
addition to buccal tisssue
Advantages
Patients own tissue
No colour match or over bulking of tissue
Disadvantages
Donor site
Technically difficult
Inadequate tissue
99. What is Straumann®
Emdogain?
• Resorbable, implantable
material
• Enamel matrix protein
(Amelogenin)
• Gel for easy handling
100. What is Straumann® PrefGel?
• pH neutral, 24% EDTA
root conditioner
• Removal of “smear layer”
before the application of
Straumann® Emdogain
• Sold separately or co-
packaged with
Straumann® Emdogain
101. Emdogain
Enamel matrix proteins of animal origin
In February 2008, at a meeting at Ittengen,
Switzerland, the 6th European Academy of
Periodontology produced three reports
supporting the use of Enamel Matrix
Derivatives in Periodontal generation.
102. CONCLUSIONS
The combination of emdogain and coronally
repositioned flaps (CRF) in miller type1 and
11 defects was comparable to CRF and
connective tissue grafts(CT).
103. Coronally repositioned flap+emdogain
Pull the flap to cover the defect
Advantages
No donor site
Disadvantages
Technically difficult
Unpredictable
Maybe adjunctive to another technique i.e.
Emdogain, free gingival graft,
mucograft,dermal graft (cost)
108. Mucograft®
Collagen Matrix
Collagen Type I + III
Porcine
FDA
BioGuide
Bilayer
Thicker
2.5-5mm (dry)
1mm (wet)
Indications…
109. Mucograft®
Smooth side (outer)
Cell occlusive
Barrier
Peritoneum
Towards soft tissue
Elastic properties allow suturing
Porous side (inner)
Collagen fibers in loose porous arrangement
Cell invasion
Pig skin
Towards the bone defect
110. Sanz et al. 2009 J Clin Periodontol
Clinical evaluation of a new collagen matrix (Mucograft
prototype) to enhance the width of keratinized tissue in patients
with fixed prosthetic restorations: a randomized prospective
clinical trial.
Increasing width of KT
CTG vs CM
CTG increased KTW by 1.7mm
CM increased KTW by 1.6mm
Shrinkage (60%,67%)
Morbidity