Anterior dental esthetics /academy of cosmetic dentistry


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Anterior dental esthetics /academy of cosmetic dentistry

  1. 1. ANTERIOR DENTAL ESTHETICS INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. CONTENTS • Introduction • Definitions • Physical attributes of the elements of the dentofacial composition • The art of illusion • Esthetic diagnosis and treatment planning • Role of technology in changing smile • Esthetic treatment planning and sequencing • Color • Treatment options • Review of literature • Conclusion • References
  4. 4. In our modern competitive society, a pleasing appearance often means the difference between success and failure in both our personal and professional lives. Scottish physiologist Charles Bell was quoted as remarking that the thought is to the word that the feeling is to the facial expression. A smile could convey a thousand different meanings , yet it is the most easily recognized expression.
  5. 5. A charming smile can open doors and knock down barriers. An attractive or pleasing smile clearly enhances the acceptance of the individual in the society and the character of the smile influences to a great extent the attractiveness and the personality of the individual.
  6. 6. But every person is not fortunate enough to have a beautiful smile . The answer to the above problem is the esthetic dentistry which has developed leaps and bounds with the latest technologies and materials. Prosthodontist is probably the best person to identify the quality of smile. Further he is also able to change the quality of smile with the recently available innovative techniques and the state of art restorative materials and to plan restorations, to harmonize with the smile.
  7. 7. CLASSIFICATION OF SMILE (Solomon E.G.R.) 1) Depending on the nature of labial mucous membrane a) papilla smile b) Gingival smile c) Mucosa smile 2) Depending on the lip component a) Straight smile b) Convex smile c) Concave
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  10. 10. Esthetics -the branch of philosophy dealing with beauty -in dentistry, the theory and philosophy that deal with beauty and the beautiful, especially with respect to the appearance of a dental restoration, as achieved through its form and / or color. Esthetic Dentistry can be defined as the art and science of dentistry applied to create or enhance beauty of an individual within functional and physiological limits.
  11. 11. Cosmetic dentistry application of the principles of esthetics and certain illusionary principles, performed to signify or enhance beauty of an individual to suit the role he has to play in his day-to-day life or otherwise. Smile designing is a process whereby the complete oral hard and soft tissues are studied and evaluated and certain changes are brought about which will have a positive influence on the overall esthetics of the face.
  12. 12. Physical attributes of the elements of the dento-facial composition The artistic parameters to be considered for essential beauty and those which are subtly present in natural beauty form the fundamental principles of esthetics. Understanding these artistic parameters of beauty and co-relaing them to the dento-facial complex will enable the dentist to appropriately scale esthetics in any dento-facial composition.
  13. 13. Composition means the act of combining elements or parts to form a whole. There are various physical attributes of the elements of a composition that impart the esthetic value. The various physical attributes of the elements of the composition are as follows-
  14. 14. Contrast: It is that factor which makes the various elements of a composition visible. The eye can differentiate the parts of an object due contrast of colors,lines, patterns, textures, etc. The relationship between the different parts of the face (facial), the teeth and the gums (dental) made visible by contrast constitutes the dento-facial composition.
  15. 15. 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. Unity between different parts of the face, and teeth is essential to give the effect of oneness or wholeness to the dento-facial composition.
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  17. 17. Cohesive and segregate forces: Any element which tends to unify a composition is a cohesive force. Segregative forces are those elements which break the monotony of the composition. Naturalness has combination of cohesive and segregative forces. A proper mix of segregative and cohesive forces adds variety to the composition making it more dynamic and interesting
  18. 18. 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 repetitive and uninteresting while the radiating symmetry looks dynamic and interesting. In a dento-facial composition radiating symmetry of the teeth is more esthetically appealing and is associated with youthfulness while horizontal symmetry is less appealing and is associated with aging.
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  20. 20. Proportion: The proportion between the various elements of a harmonious composition, in which the cohesive and segregative forces are equally balanced,and which has its various units in an esthetically appealing respective proportion to each other is the golden proportion
  21. 21. Dominance: It exists when a strong centralized structure is surrounded by well-demarcated, characterized structures. In a dento-facial composition it creates immaculate unity leading to a harmonious composition. The absence of dominance makes the composition weak. Color, shape and size are the factors which can control dominance).
  22. 22. Balance: It is achieved when there is an exact equilibrium between the forces present on either side of the fulcrum in a composition. In dentistry this implies the balance of the elements in relation to the midline.
  23. 23. Visual tension is the tension brought about by the presence of certain elements that cause an imbalance in the given composition. If the presence of these factors is closer to the fulcrum, the tension induced is more magnified as against their presence farther from the fulcrum.
  24. 24. The esthetic orientation of the dental composition with the entire facial composition can be achieved by taking into consideration the -- references, -- smile elements, -- proportions and -- symmetry.
  25. 25. The dento-facial frame constitutes the teeth and gingiva related to the lips and then to the entire face. The oral frame is determined by the anatomy and mobility of the tissues when in function surrounding the teeth and gingiva .The exposed portion of the oral elements i.e. teeth and gums within the oral frame during a smile is called the smile window. .
  26. 26. References can be classified as -- horizontal references, -- vertical references, -- sagital references and -- phonetic references.
  27. 27. Horizontal references: The horizontal perspective of the face is provided by the interpupillary line the commissural line. The inter-pupillary line helps to evaluate the orientation of the incisal 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 inter-pupillary line. This helps to diagnose any asymmetry in the tooth position or gingival location.
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  29. 29. Vertical references: The facial midline serves to evaluate the location and axis of the dental midline and the medio- lateral discrepancies in tooth position.The inter- pupillary line and the facial midline emphasize the ‘T’ effect in a pleasing face. The dental midline, if perpendicular to the inter-pupillary line and coinciding with the bridge of the nose and the philtrum, produces an attractive orientation of the smile.
  30. 30. Axial inclination is the direction of the anterior teeth in relation to the central midline and becomes progressively more pronounced from the central incisor to the canine. There is a definite mesial inclination to all the anterior teeth related to the midline. The axes of the premolars and the first molar on either side also show mesial inclination in relation to the midline.
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  32. 32. The perception of tooth inclination can be viewed from the frontal aspect around the central vertical midline, which acts like a fulcrum around which axial inclination of teeth on either side exhibit a phenomenon of balance of lines. Deviations in axial inclination cause a visual tension when beyond the point of equilibrium
  33. 33. Sagittal references: Soft tissue analysis at a standardized position helps in studying the profile of an individual. The contours of the upper and lower lip support is determined by the position of the anterior teeth and can be used as a guide for the placement of teeth when planning restorations. The lip protrusion, the amount of prominence of chin, recession or prominence of the nose and its degree, all help in profile analysis for diagnosis and treatment planing.
  34. 34. The E-line or esthetic line is an imaginary line connecting the tip of the nose to the most prominent portion of the chin on the profile, ideally the upper lip is 1-2 mm behind and the lower lip 2-3mm behind the E-line. Any change in the position of the E-line indicates the abnormality in the upper or lower lip position.
  35. 35. The relationship of the maxillary incisl edges to the lower lip is a guide for the placement of the incisal edge position and length. The pronunciation of the ‘F’ and ‘V’consonants helps determine the position of the incisal edges. On pronouncing ‘F’ and ‘V’ the incisal edges should make a definite contact at the inner vermilion border of the lower lip Thus the position of the incisal third of the maxillary central incisor can be determined.
  36. 36. Phonetic references: ‘F’ and ‘V’ sounds 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 relaxed rest position and repeated at slow intervals can help evaluate 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
  37. 37. Smile elements: The extent of the smile is outlined by the curvature of the upper and lower lip and the position of the angle of the mouth, and it determines the degree of exposure, both in the anterior and posterior teeth, gingiva as well as the width of the buccal corridor
  38. 38. Lip and lip lines: The length, the curvature and the shape of the lips significantly influence the amount of tooth exposure during rest and in function. A prominent tooth display is associated with a youthful smile and most patients would like to seek the benefit of the same. Some researchers demonstrated that the average maxillary incisor display with the lips at rest is 1.91mm in men and 3.40 mm in Women Patient’s with short upper lips and younger patients generally display more maxillary tooth structure which may be up to 3.65mm.
  39. 39. Upper lip line helps to evaluate the length of the maxillary incisor exposed at rest and during smile and the vertical position of the gingival margins during smile. The upper lip line can be classified as low, medium or high depending upon the amount of tooth or gingival display that is available during a moderate smile. The gingival margins may be displayed in high lip line cases. The most apical position of the gingiva over the facial aspect of the maxillary central incisor and canine is slightly distal to the long axis of the tooth while in the maxillary lateral incisor it is at the long axis of the tooth. This is called the gingival zenith
  40. 40. Whenever a patient displays the gingival margins easily on smiling or speaking, a definite pattern of the gingival display can be recorded. This pattern can be either esthetic or unesthetic A smile can be termed “toothy” if more than 6mm of incisal display is seen at rest position or “gummy” if more than 3mm of gingival tissues are displayed in moderate smile)
  41. 41. Lower lip line helps to evaluate the buccolingual position of the incisal edge of the maxillary incisors and the curvature of the incisal plane
  42. 42. Smile line: It is an imaginary line passing through the incisal edges of the upper anterior teeth. The smile line usually coincides or runs parallel to the inner vermilion border of the lower lip. In a youthful smile the incisal edges of the central incisors and canines are aligned on a convexity, incisal embrasures gradually deepen from central incisor to the canine, giving the appearance of the wings of a gull. Thus the incisal plane is said to have a gull-wing appearance Reduced incisal embrasures and leveling of the gull-wing effect as in a straight smile line is associated with
  43. 43. Negative space: Negative space is a dark space appearing between the jaws and the mouth opening either at the corner of the mouth of around the buccal aspect of the posterior teeth during active smile and laugh.
  44. 44. Progressive abating in a dental composition: When similar structures are aligned in an arch form one after the other, they appear to progressively abate in size from the nearest to the farthest. This gives an illusion of depth. The presence of poorly shaped teeth, differences in axial inclinations, tooth length discrepancies, discolorations, gingival disharmonies etc. can lead to a visual tension resulting in a disruption of the front to back progression.
  45. 45. Proportion When mathematics is applied to the study of ideal tooth form, a numerical relationship is established within a single tooth form (ideal proportion) and also between a series of teeth in the arch (relative proportion). The position of the tooth in the arch, the relationship between the width, the length and the face of the tooth can also be numerically established in relation with certain anatomic landmarks.
  46. 46. Gold Proportion is expressed in numerical form and applied by classical mathematicians such as Euclid and Pythagoras in pursuit of universal divine harmony and balance. It has been applied to a lot of ancient Greek and Egyptian architecture and may be expressed as the ratio 1.618:1:0.618
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  48. 48. Symmetry For harmony, certain symmetries are essential while certain asymmetries are acceptable. Harmonious facial features should be more symmetrical close to the facial mid line and can be more asymmetrical away from the facial midline.
  49. 49. Smile Dominance : Different facial features stand out differently in the eyes of every beholder. In certain cases, the most predominantly striking features of a face is the smile; these are the “Dominant Smiles”. • The maxillary central incisors exhibit a strong presence by their size and form reflecting the personality of the individual. • The maxillary lateral incisors and the canines complement the cement incisor in terms of proper shape and form.
  50. 50. PERCEPTUAL ASPECTS – THE ART OF ILLUSION Illusion is an imagination where a perception of an object is created. Fundamental and Principles The art of creating illusions consists of changing perception, to cause an object to appear different from what it actually is. Teeth can be made to appear smaller, larger, wider, narrower, shorter, longer, younger, older, masculine or feminine.
  51. 51. One being subjected to light the most fundamental objects exhibits two dimensions, that is, length and width. True natural light is multi-directional and on striking the surface of the object, also reveals texture and shadows, this adds the third life like dimension of depth.
  52. 52. Cosmetic contouring Cosmetic contouring by definition is the reshaping of natural teeth to make them esthetically pleasing. In natural dentitions, variations seen in tooth shape and size some times violate the acceptable width to length ratios as well as the golden proportion. Minor adjustments in contours to change the perception of these proportions increases the esthetic acceptability to a great extent. It is indicated for giving a pleasing appearance to fractured, chipped, extruded, malformed or over lapped teeth
  53. 53. ESTHETIC DIAGNOSIS AND TREATMENT PLANNING Total Smile Analysis Total smile analysis is a cumulative inference analysis, drawn by interpreting and integrating various analysis like a visual , space ,profile and computer analysis after performing the preliminary analysis.
  54. 54. Space Analysis It helps the dentist to gauge the amount of space available during the treatment planning stage. The concept is to measure the widths of all the teeth and to compare it with space present in the arch. This determines whether the space available for restorations and natural teeth is less or more than required. Disproportionate spaces may be due to discrepancies in jaw and tooth size, malformed teeth, missing teeth, mal-aligned teeth etc. The space analysis will provide a guideline or a frame work within which the esthetic dentist has to plan each restoration.
  55. 55. Corrections of labio-lingual inclinations and rotations of the teeth by restorative procedures will result in a change in the width space ratio due to the change of angulation involved. For any changes proposed that may involve alterations in the width of the anterior teeth, the law of golden proportion should be closed followed. This enables the esthetic dentist to plan any space manipulations for the restorations in terms of illusions, actual tooth positional changes such as rotations overlaps, spacing etc.
  56. 56. Profile analysis While examining the patients profile, the normal profile is referred to as straight orthognathic. Any deviation from this should be recorded and considered in treatment planning.
  57. 57. Profile analysis helps in treatment planning of the cases that will require skeletal correction in addition to the esthetic restorations for complete esthetic success. This will ensure that the skeletal and non-skeletal aspects of the treatment plan are segregated and treated for a comprehensive, successful esthetic treatment.
  58. 58. Computer Analysis The new intra-oral cameras with digital support and the radio-visiographs are indispensable tools at the esthetic dental office. They give enlarged images of the photographic and radiographic outputs on the screen, with multiple magnifications, and at various angles, for the dentist as well as the patient to assess and view the intra oral condition in a different perspective.
  59. 59. ROLE OF TECHNOLOGY IN CHANGING SMILE New technology helps us to preview the end results.The following high tech tools can be incorporated: 1) Extra oral video camera: It allows to have a detailed record of the patient's face while moving and talking. It can record the patient in various moods and gestures and give us the minute details the patient may be unaware of. This can be shown to the patient with the help of computer imaging . Different smiles and profiles can be applied to the patient's face and the patient can be given the opportunity to choose the best smile design
  60. 60. 2) Intraoral video camera: Intra oral examination from every angle with the smallest details can be viewed as close as 2mm. from the tooth. With it we can explain certain conditions and treatment options much more accurately. Introral cameras can be integrated with a computer imaging system to capture the detailed images of the patient's oral cavity. These images can be modified according to the proposed treatment options and shown to the patient.
  61. 61. 3) Computer or voice activated data Using voice activated technology , we can document our findings by speaking into the microphone that are connected to a computer which has been "trained" to recognise a limited vocabulary. The computer then stores the infomation and even graphics( related to smile ) so that various procedures can be discussed with the patient.
  62. 62. 4) T- Scan and Digital Radiography By using this scan , buccolingual width of the jaws as well as the location of anatomic features such as the mandibular canal and the maxillary sinus can be determined which is useful while placing an implant in the esthetic position.
  63. 63. 5) CAD/CAM With CAD/CAM ( Computer assisted design/ Conputer assisted manufacture) technology we can design veneers and crowns to enhance smile while the patient waits. The so called "mock- up" of a planned cosmetic teatment also has been shown to be quite useful. It also allows clinician to visualise the desired results and solve potential problems before providing treatment to the patient.
  64. 64. 6) Lasers The dental lasers uses a beam of light in place of scalpel to perform delicate gum surgery and crown lengthening/ gingivectomy and gingivoplasty. The advantages of this procedure are- 1) Controlled bleeding which provides dry operating field and hence excellent visibility. 2) Reduced operating time and reduced post operative swelling, pain and scarring.
  65. 65. 7) Computer Imaging It improves communication between the patient and the dentist by allowing both to visualize , evaluate and agree on treatment. It allows to " see" various looks before deciding upon treatment.
  66. 66. 8) Computer Controlled Injection Technique The P- ASA (Palatal approach anterior superior alveolar ) is a new block injection technique that provides anaesthesia of the maxillary anterior teeth from a single injection without numbness of the face , lips and the muscles of facial expression. The injection can be administered in a comfortable and consistent manner, using a computer controlled local anaesthetic delivery system. This technique prevents distortion of the smile line and enhances restorative procedures that use the lipline as an esthetic reference element.
  67. 67. 9) Abrasive Technology In this technique , a jet air stream with micro abrasive particles is used to remove the stained areas. It is painless, faster and does not require the use of anesthesia. It can be used in any quadrant for any depth of decay without damaging the healthy tooth structure. After the removal of the stained areas , the tooth structure can be built up with composite. It is also useful during repairs to existing composite or porcelain restorations because it roughens these surfaces allowing the reparative materials to bond them more rapidly .
  68. 68. COLOR Dimensions of color Color cannot be perceived without light, which is a form of electoro-magnetic energy visible to the human eye. The visible spectrum of light lies in a narrow band of 380nm to 760nm. It has the ability to stimulate the cells in the retina which is interpreted by the brain, discerning the sense of color.
  69. 69. Clark stated that “Color, like form, has three dimensions”. Hue, which is the name of the radiant energy, Chroma, which is the saturation of the hue and value, which is the relative lightness or darkness of the color. Since clinical color matching depends upon the ability of the dentist to perceive the difference in the tooth shade guide comparison; complete understanding of the color dimensions is critical. The Munsell color order system best serves the needs of the dental profession in its attempt to visualize and organize color.
  70. 70. Hue : In Munsell’s words, “It is that quality by which we distinguish one color family from anther”. Chroma :In Munsell’s words, “it is the quality by which we distinguish a strong color from a weak one. “Human teeth fall into the yellow to yellow red area of the Munsell color order system. Pale colors have a low chroma whereas intense colors have high chroma.
  71. 71. Value : Value or brilliance is the relative blackness or whiteness of color. On a scale of black to white, white has “high value”, black a “Low value” and Midway between black and white is the medium grey.
  72. 72. Shade selection Shade selection is a complex procedure due to the variations and differences in the optical properties of the new generation of cosmetic restoration materials. It can be well accomplished by understanding the fundamentals of color and adopting a proper methodology of matching shades. The effective communication with the laboratory and precise fabrication and meticulous finishing of the restoration will affect the color of the final restoration.
  73. 73. Shade selection sequence Any color modification procedures like bleaching or microabrasion should precede color selection after ensuring color stabilization. • Make the shade selection at the beginning of the procedure as well as over different appointments (diagnosis, prophylaxis etc.)and cross check these observations. • View the patients at eye-level. The operator should stand between the light source and the patient. • In a contrasting environment, colors look more intense and brighter. Hence it is wise to ask the patient’s to remove artificial lip
  74. 74. • Place the tabs as close as possible to the area that is being checked. • Moisten the tab and eliminate the worst match. • Evaluate the value (upper to lower). Value is the most important factor in shade matching. If the value blends, small variation in hue and chroma will not be noticeable. The value is to be matched with eyes half closed. • After value, mark the translucency • Match the chroma (more or less saturated) and finally, hue in that order.
  75. 75. Dental Bleaching Bleaching is one of the most commonly sought elective dental procedures to brighten a smile. It is a simple, fast and effective treatment to change darker tooth shades into lighter ones. Chemistry of bleaching Bleaching process is based on the oxidation of bleaching agent. Oxidation is the chemical process by which organic materials are converted into carbon dioxide and water. The oxidation reduction reaction that takes place in the bleaching process is called the redox reaction.
  76. 76. Office bleaching of non vital teeth The two most commonly used agents for bleaching of non-vital teeth are hydrogen peroxide and sodium perborate. Home bleaching Bleaching may be carried out at home by the patient. The home bleach technique involves the application of bleaching agent through the use of vacuuform trays. The frequently used bleaching agent is 10% - 15% carbamide peroxide.
  77. 77. Esthetics with composites The preparation design for anterior composite restorations should encompass elimination of decay, function and longevity, and esthetic predictability.
  78. 78. To create proper tooth from, shape, shade and texture, and to optimize function, all cavity preparations designs should have extension for function and esthetics (EFE).
  79. 79. The Extension for Function and Esthetics ensures that the margin of the restoration overlays the defects. The esthetic advantages are : • Successful masking of the defect • Better marginal adaptation • Natural transition of shade between composite and tooth • Ease of finishing and texturing
  80. 80. Esthetics with Ceramics Ceramics laminate veneers In 1930 Charles Pincus used a unique procedure to improve the smiles of certain Holly wood actors. This technique was non-invasive and gave good esthetic results with resin and air fired ceramics.
  81. 81. Metal ceramic and all-ceramic restorations Metal ceramic and all ceramic restorations have excellent esthetic potential. The metal ceramic restorations owe their popularity to the simplicity of bridge construction, durability, strength, marginal adaptation and versatility of use.
  82. 82. Pre-implant esthetic consideration In cases of anterior implants in the esthetic zone, certain specific esthetic criteria have to be considered. When esthetics is the prime reason for seeking implant prosthetic treatment, the patient’s upper lip line will be of extreme importance for the planning of the definitive superstructure.
  83. 83. The single tooth anterior implant situations is of great concern as the esthetic requirements and expectations have to be properly balanced keeping in mind anticipated post-surgical results. The dentist should analyze anterior single tooth implant situations considering the adjacent teeth, contra-lateral tooth, probable emergence profile and presence or absence of inter dental papilla whenever the active smile exposes enough of gingival tissues.
  84. 84. Apart from the inadvertent deficiencies in the facial bone associated with various clinical situations, the soft tissue form also plays a major role in the esthetic outcome of single tooth implants. In 1989, Misch reported 5 prosthetic options available in implant dentistry. The first three options are fixed prosthesis (FP). The next two options are removable prostheses (RP).
  85. 85. Prosthodontic classification FP – 1Fixed Prostheses, replaces only the crown, looks like a natural tooth. FP – 2Fixed Prostheses, replaces the crown and a portions of the root; crown contour appears normal in the occlusal half but is elongated or hyper contoured in the gingival half. FP – 3Fixed Prostheses ; replaces missing crowns and gingival color and portion of the edentulous site; Most often uses denture teeth and acrylic gingiva, but may be porcelain too
  86. 86. RP – 4 Removable prostheses ; over denture supported completely by implant. RP – 5 Removable Prostheses ; over denture supported by both soft tissue and implant.
  87. 87. Esthetic periodontal defects and its correction Periodontal defects posing an esthetic problem. May include : • Violations of biologic width • Gingival asymmetries • Excessively gingival display • Localized gingival recessions • Deficient pontic areas • Abnormal frena. • Excessive gingival pigmentation • Inadequate interproximal papilla
  88. 88. The possible causes of gingival asymmetries are : • Gingival hyperplasia • Altered passive eruption • Tooth or teeth malpositioning • Over zealous tooth brushing • Periodontal disease
  89. 89. Impaired dento-facial esthetics and function due to absence of canines. The position of canines in all three planes of space is very important from esthetic and functional point of view. The ectopic eruption and impaction of maxillary permanent canines is a frequently encountered clinical problem. The canines also provide the main gliding inclines for lateral excursions of the mandible.Thereby providing the patient with a functional occlusion.
  90. 90. Therefore, it is not only important to get healthy favorably positioned impacted teeth into occlusion but also to position them in such a way that they maintain the integrity of occlusion, provide good function and optimal esthetics.
  91. 91. Establishing proper anterior guidance Proper inter-incisal relationship is important to maintain the vertical position of incisors. Loss of this relationship leads to supra- eruption of incisors and deep bite.
  92. 92. In severe deep bite case, there is often attrition of lower incisal edges and the palatal surfaces of upper incisors, leading to shorter clinical crowns of the lower incisors and lack of anterior guidance. In such a clinical situation, if there is any restoration in the maxillary anterior region, it will have a tendency to debond due to lack of sufficient vertical clearance.
  93. 93. Therefore, it is necessary to establish proper anterior guidance with orthodontics so that the palatal surfaces of upper anteriors could provide a harmonious glide path for the lower anterior teeth during the protrusive excursion of the mandible. These teeth should work against one another to separate or disocclude the posterior segments as soon as the mandible moves out of centric closure.
  94. 94. Ortho-Perio –Restorative Perspective An integrated orthodontic, periodontal and restorative treatment is useful in wide variety of patients for improved occlusual relationships of teeth, proper gingival architecture and esthetic, biologically sound restorations.
  95. 95. During the process of eruption the whole periodontal apparatus is carried with the erupting tooth. When there is asymmetric eruption of the teeth it will also result in discrepancies in heights of the underlying crestal bone. This, in turn, results into asymmetries in gingival heights (gingival zenith) from one side of the arch to the other. This type of a clinical situation can be managed orthodontically by intrusion or extrusion of teeth. Forced eruption Forced eruption is one of the adjunctive orthodontic treatment procedures where controlled vertical extrusion of a tooth is carried out to improve the prognosis of other treatment
  96. 96. REVIEW OF LITERATURE • E M Narcisi, J A DiPerna ; highlights the harmonious integration of modern smile design, material selection, and interdisciplinary communication that must be addressed in order to deliver optimal treatment with porcelain laminate veneer and laboratory-fabricated resin inlay restorations. J Esthet Dent Assoc 2001 • Singer BA. introduced to the literature a framework for understanding artistic principles as they relate to clinical cosmetic dentistry, ie, shaping teeth and creating illusions J Esthet Dent Assoc 1994
  97. 97. • Carlos Eduardo Francischone et al ; stated that with the integration of many specialities, it is possible to achieve the desired esthetics for anterior prostheses and to develop a harmonious transition to the surrounding periodontium. JPD 2000 • Roy Sabri ; concluded that missing maxillary lateral incisors with any coexisting malocclusion must be managed within an overall treament plan. JIPS 1999 • Messing MG ; Factors related to patient , size, shape and position and color of the teeth ; the effect of occlusion; the overall facial and dental esthetics should be considered when deciding on whether to create an orthodontic space opening or space closure. J of Esthet Dent, 1999
  98. 98. CONCLUSION • Dentistry is an ever changing science. As new research and clinical experience broaden our knowledge, changes in treatment are required. This shift in the field of dentistry comes along just in time to meet the final needs and wants of patient who perceives an attractive smile no longer as a luxury but rather a necessary part of their life style. • Aesthetic dentistry enables the dentist to change the appearance, size, color, shape, spacing and positioning of the teeth.
  99. 99. REFERENCES • CLAUDE R. RUFENACHT, fundamentals of esthetics • RONALD E. GOLDSTEIN, change your smile 3rd ed. • CHICHE, esthetics of anterior fixed prosthodotics • GOLDSTEIN, complete dental bleaching. • GARDIN, Porcelain laminate veneers • Solomon EGR: Esthetic consideration of smile; J of IPS 1999: 10(3&4); 41-47 • Goldstein, RE: Change your Smile, ed 3 Chicago, Quintessence, 1997. • Messing MG The role of cosmetic dentistry in restoring a youthful smile: J of Esthet Dent, 1999
  100. 100. • Kamal Shigli, Swaraj Bharati: Role of technology in designing a confident smile. J. IPS Dec. 2001, vol.1, no.4.6) • Friedman, MJ and Hodcman, M.N.: P-ASA Block injection: Anew palatal technique to anaesthetize jmaxillary anterior teeth: J of Esthet Dent, 1999; 11(2): 63-77.
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