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  1. 1. 84 AESTHETICS Advanced Smile Design Technologies entistry has certainly come a long D way since the barber shop image of the past. Today, digital technology affects every aspect of the profession, and patients use the Internet to search for qual- ified dentists who specialize in smile design. Bacon’s Media Source reports that the average monthly circulation of articles Peter D. about cosmetic dentistry reached 40 mil- Vastardis, DMD lion in 2004. And that includes only print media—not television.1 The computer has made smile design cosmetic simulations possible with exact color-matching capabilities, and new com- puted tomography (CT) images with 3-D views of the patient to help with virtual planning and surgery is a reality. Cone beam CT technology, which uses a different approach to conventional CT, is remarkable Figure 1. Preoperative full facial view. Figure 2. Interactive Smile Style Guide. in its ability to acquire whole volume data during a single sweep of the scanner. Patient expectations can be obtained with accuracy via computers and software, as long as they fit scientifically into the proto- cols of our original, tested systems. For years, many dental offices have been using CAD/CAM systems such as Sirona CEREC technology to fabricate restorations during a single visit. Others have begun using the Cadent iTero system, which is the first all-digital solution for fabricating den- tal restorations using an intraoral scanner Figure 3. Modified Golden Proportion grid for diagnos- Figure 4. Facial analysis using GPS. to create an accurate 3-D image of the pre- tic wax-up. pared tooth. In recent years, dental labora- tories have begun to acquire contact scan- ners such as the Procera (Nobel Biocare) to protocols. This involves proper planning of proven to be predictable protocols that den- help design and mill a restoration using the aesthetic component in advance so that tists must evaluate prior to performing the computer-assisted design. expectations are discussed and realized dental makeover. Along with these scanner advance- prior to any tooth preparation. 1. Line angles: the area where the facial ments, cutting-edge dental software has The rules of smile design are the archi- surface of the tooth turns interproximally evolved to help dentists design a smile that tectural blueprints for the dentist, the into the contact area. allows patients to choose tooth shapes, patient, and the laboratory. Smile design 2. Outline form: the shape of each sizes, colors, etc—all with just the software evaluates the deficiency of balanced aes- respective anterior tooth when mesial and and a digital camera. thetic characteristics from an objective distal line angles and the incisal and gingi- standpoint, but precise protocols allow the val aspects of a tooth are connected. THE AESTHETICS OF SMILE DESIGN dentist to achieve a more subjective goal— 3. Embrasure spaces: these must be eval- The creation of a smile design requires the the specific aesthetic wishes of the patient. uated to determine if they increase slightly dentist to prepare an aesthetic dental Collectively, the following aesthetic as the teeth go from central to canine. makeover by using several indispensable characteristics of smile design have been continued on page 86 DENTISTRY TODAY • DECEMBER 2007
  2. 2. 86 AESTHETICS Advanced Smile... maxillary teeth. From cen- coincidental with the dental 12. Facial assessment: continued from page 84 tral to canine, there should midline for the perception of this is necessary to deter- By using percent- be a subtle increase in me- symmetry? (ie, Is the vertical mine if there are asymme- sial inclination when view- plane 90° to the horizontal tries that make it difficult to ages to help design ing a patient’s smile from plane that we determine from use certain facial anatomic a balanced smile, the the front. the eyes and lips?) If there is landmarks to establish spa- 5. Contact points: these an imbalance, the aesthetic tial relationships for the analyses of symme- gradually decrease from cen- strength is reduced. teeth. We often use the nose, try, dominance, and tral to canine. The more 10. The Rule of Golden chin, and eyes to help us de- youthful the teeth, the more Proportion: a mathematical termine midline placement, proportion of each apically positioned the inter- rule that defines a specific ra- but the entire dento-facial tooth within the ante- dental contact. The more tio between dimensions of a complex must be weighed incisal the contact is placed, larger length to a smaller because the features and rior segment can be the more mature the teeth length. As you look straight facial forms of each patient evaluated for their will appear. at an anterior situation, the are unique.6 The first consid- contribution to the 6. Gingival levels: does width of the central has a eration is the outline form the upper lip follow the level mathematical relationship of the patient’s face (facial entire smile. of the upper gingival archi- to the width of the lateral to shape)7 and what outline tecture? Do the incisal edges the smaller width of the cus- form, therefore, should be Figure 5. Facial/dental determina- of the maxillary teeth follow pid. The ratio of the Golden created for the teeth. pealing, youthful smile that tion using GPS. the lower lip line? Proportion has long been a. A round face can be included whitening her teeth 7. Buccal corridor (ves- considered to create an aes- made narrower by elongating and replacing the old, dis- tibular space): this is the thetically perfect appearance the teeth. colored restorations. First, I space between the maxillary of harmony and balance. If b. A narrow face will reappointed her for a com- posterior teeth and the inner the laterals are a factor of 1, appear wider with a flatter prehensive medical/dental cheek. Depending on arch then the centrals are 1.618, smile line. examination that consisted width, soft-tissue patterns, with the size of the laterals c. An oval face can accept of a functional analysis of and muscle, the most ap- looking straight on from the many different smile designs. her TM joints, including load pealing smiles have little or front, and the cuspids 0.618 d. A square face can be testing, palpation of her mus- no negative dark buccal cor- of the size of the laterals. made to look more oval with cles of mastication, range of Figure 6. Preoperative photo of anterior teeth. ridor space.2 While the Golden Proportion proper smile design. Long, mandibular motion/doppler 8. Incisal edge position: cannot always be achieved, narrow teeth, for example, auscultation, a full series of this is second in importance we strive to get as close to it will elongate the face, while digital radiographs/panorex, to centric relation, according as possible. For example, square teeth will accentuate 12 American Academy of to Dawson. The key control- closing a diastema may re- the square facial appearance. Cosmetic Dentistry preoper- ling factors are the contour quire a slight deviation from e. A heart-shaped or ta- ative digital photos, soft- and position of the labial sur- the Golden Proportion—some- pering face can be de-empha- and hard-tissue evaluation, faces of each tooth. If the thing that Stephen Snow, sized with flatter teeth. periodontal probings, face- incisal edge is to be changed, DDS, calls the Golden Per- 13. Phonetics: the sounds bow (Rotofix [Jensen In- it is best to first accomplish centage. By using percent- produced when speaking are dustries]) mounted study Figure 7. Post-bleaching of posteri- this with temporaries to ages to help design a bal- shaped mechanically by the models on a semiadjustable or maxillary and entire mandibular evaluate controlling factors anced smile, the analyses of combination of teeth, lips, articulator (Artex [Jensen arch. intraorally, and placement symmetry, dominance, and and tongue. The F sound Industries]) with CR bite should be assessed in rela- proportion of each tooth with- helps to guide us in placing records using a lucia jig tion to the patient’s lip mo- in the anterior segment can the upper incisal position in (Great Lakes Orthodontics), bility. Anterior guidance must be evaluated for their contri- the correct plane. Pre-evalu- and an evaluation of her also be maintained or devel- bution to the entire smile.5 ating the position of the entire dento-facial complex oped where necessary.3 The 11. Occlusal plane: Is incisal edges with the speech using the Dr. Jose-Luis central incisor is approxi- there an acceptable occlusal pattern of your patients can Ruiz aesthetic diagnosis mately on the same plane as plane especially with an em- help you assess where to cor- form. This form helps to the tips of the canines and phasis on the incisal plane of rectly place the edge in wax diagnose the patient’s exist- the buccal cusp tips of the the anterior teeth? Does the and then intraorally in the ing dento/facial problems, Figure 8. Stumpf shade determina- premolars and molars. Spear imaginary line touching the temporaries for the final aes- as well as determine her tion. tells us that the more mobile incisal edges of the maxillary thetic determination. desires and expectations.8 the lip, the less we can show anterior teeth and the inter- Upon clinical examina- the incisal edge at rest, while pupillary line appear level A CHALLENGING CLINICAL tion, we discovered that the the less mobile the lip, the when using the simple rule of EXAMINATION AND patient had trauma to her more we must show at rest aligning the face-bow with DIAGNOSIS face, especially to the left to create the most appealing the eyes? Dawson tells us A 20-year-old woman came to cheek area immediately smile. Ideally, the incisal that there are few mistakes my office complaining of an under the eye, chin, and edge should just touch the that affect aesthetics more unbalanced smile with dis- lower left border of her lip. A dry side of the wet-dry inner negatively than a slanted colored teeth and aged com- permanent scar was appar- vermillion border of the incisal plane. Is the labial posite and porcelain veneer ent to the lower lip, both at Figure 9. Shade determination lower lip.4 surface of the central to the restorations. She had been the wet and dry border, using Vita 3-D Master Shade Guide. 9. Dental/facial midline: occlusal plane near or about in a severe automobile acci- which gave it a swollen ap- this is another important cri- 90 degrees to the occlusal dent a few years earlier, which pearance. Her lip and chin terion because you want a plane, which is the most had caused extensive facial also had permanent devia- 4. Axial inclination: the cohesive succession of coinci- pleasing angle? How are the and dental trauma, and teeth tions (Figure 1). known fact is that all teeth dental lines that are in bal- curve of Spee and the curve of Nos. 7 to 10 had been restored Radiographic evidence re- have their own long axis ance with the dentition, Wilson? Properly mounted with direct bonding and por- vealed that she had had alignment that compares to dentofacial, and facial com- casts are a must for determi- celain crowns. endodontic therapy to teeth the vertical alignment of the plexes. Is the facial midline nation of these variables. She wanted a more ap- continued on page 88 DENTISTRY TODAY • DECEMBER 2007
  3. 3. 88 AESTHETICS Advanced Smile... have periapical pathology. dental personality. I find to be waxed up to this pro- instills a level of confidence continued from page 86 Initially, she was referred to that this co-discovery with portion (Figure 3). The proj- in the patient for the rest of her endodontist to evaluate the patient is invaluable for ect can also be digitally e- the treatment sequence. Once the large radiolucencies, and the success of the aesthetic mailed to the laboratory or the patient was satisfied the endodontist felt that due case. Once I feel that the periodontist. Figure 4 shows with the bleaching results, I to the large posts and reim- patient’s expectation is with- the simulation of the pa- waited a few weeks because plantation, there would be a in my reach, I can proceed tient’s pre-existing smile. vital bleaching with even risk of fracture if we tried to with the smile design. The vertical bands show the 10% carbamide peroxide remove the posts and retreat existing midline, buccal, and causes a significant reduc- the teeth. Preparation vestibular space. tion in the natural amounts Figure 10. Final glazed indirect Therefore, we offered to Thankfully, we have many Figure 5 shows the true of calcium and phosphorus Luxatemp temporaries. have an endodontist treat modern tools to help us diag- interpupillary, midline, and found in enamel. Haywood her with apicoectomies or nose an aesthetic case using occlusal level for this pa- states that we should allow have her teeth removed and the above parameters of tient. You may simply want for color stabilization and replaced with implants. She smile design. First and fore- to move the midline 1 mm, remineralization in order to opted to try to save her most, the visual information adjust the occlusal level to ensure sufficient bond strength teeth, and I advised her that that digital dental photogra- correct any canting, and before continuing with re- when metal posts are pres- phy provides to the patient, alter incorrect tissue levels storative therapies.10 ent, the natural transmis- dentist, ceramist, and any and contact points with this Tooth preparation began Figure 11. Final Empress sion of light through all-por- other specialist involved is software. with the removal of the old crowns/veneers. celain crowns and down to indispensable. Instant digi- The software takes you restorations and all evident the tooth’s root is impossible. tal images can allow the through a step-by-step proc- decay, which was unfortu- Since I believe it is often pre- photographer to immediate- ess to answer certain ques- nately excessive in teeth Nos. ferable to articulate possible ly evaluate the desired im- tions according to the desires 9 and 10 (Figure 8). problems before treatment is age that will be used with of the patient and dentist, There was an excessive initiated, I wanted her to the advanced technologies and your answers can be degree of discoloration, and understand that she would that follow. adjusted as necessary. the stumpf shade guide re- Figure 12. Final Empress restora- probably have dark discol- New and innovative soft- After you have entered vealed an even darker color tions showing internal effects. oration around the gingival ware called the Guided Po- all of the necessary informa- than the St.3 shade tab at margin as compared to her sitioning System (GPS [my- tion in the software, the lab- the gingival one third of other teeth. Therefore, we]), developed oratory can provide you with tooth No.10. Although most discussed exactly what she by Dr. Alain Methot,9 takes a diagnostic wax-up of the dentists use this guide for wanted versus the realistic digitized images of the pa- case. Obviously, a wax-up is prepared teeth, I have had results I could provide her. tient’s facial view at 1:10 an educated guess, and the equal success simply using We discussed her dissat- ratio and studies them using intraoral temporaries are the classic Vita shade guide isfaction with the overall a step-by-step system for the best means of evaluating (Vident) with digital photog- color of her teeth, the exist- dental aesthetics. This sys- the proposed smile design. raphy to assist me in closely ing aesthetic concerns I felt I tem allows the restorative Once the patient approves matching the existing stumpf Figure 13. Postoperative 1:1. could improve, and the smile dentist to utilize specific the case, you can proceed shade and relaying this infor- design that she preferred. parameters of smile design with the permanent smile mation to my ceramist. My goal was to create pro- with technological accuracy. design. With this particular Two images are very im- portionate, symmetrical di- The values that are entered, patient, she needed slight portant for shade communi- mension to her incisors and which are obtained clinically tissue augmentation to pro- cation. The first involves transform her smile into a during the photography ses- vide a more desirable level taking the 2 closest value softer, more youthful, femi- sion, are the interpupillary (Figure 6). shade tabs to the teeth. One nine appearance. Using new distance, the width of the cen- The patient’s next wish is a bit higher in value, while software called the Inter- tral incisors, and the inter- was to brighten her teeth. the second is a bit lower. The active Smile Style Guide molar distance. Using a take-home 16% second image is for chro- Figure 14. Postoperative right lat- (iSSG {]) co- The software determines bleaching system (Nite- ma—again, one tab provid- eral view showing canine guidance. developed by Drs. Lorin Ber- what Methot calls the Mod- White ACP [Discus Dental]) ing a shade higher and one land and David L. Traub, I ified Golden Proportion For- for several weeks, she at- lower. Taking the images of discussed cuspid, lateral, mula, which is specific for tained her desired shade the shade tabs in the same and central incisor tooth each patient. It establishes (Figure 7). This bleaching vertical plane allows the shapes and sizes with the the correct guidelines, proto- system combines the bene- quantity of surface light re- patient. I wanted to get a cols, and dimensions to en- fits of carbamide-hydrogen flection to be equal.11 I chose feel for her tooth dimension sure that the postoperative peroxide with a patented the excellent aesthetic den- preferences. By using this simulation results will match amorphous calcium phos- tal team that Daniel Mater- cutting-edge technology on the desired balanced smile phate (ACP) technology, po- domini, MDT, has put to- my computer monitor, we as closely as possible. Using tassium nitrate, and fluo- gether at daVinci Dental Figure 15. Postoperative left later- could easily show her specif- the photographic protocol in ride. This has allowed for an Studios, using IPS Empress- al view showing canine guidance. ic tooth shapes and sizes the dental GPS, axial incli- increase in patient comfort pressed veneers (Ivoclar step by step (Figure 2). nations, length of teeth, soft- and compliance. Note how Vivadent). Over the years, I spent considerable time tissue levels, contact points, wonderfully the posterior they have provided my prac- Nos. 8, 9, and 10, and teeth with her to get a sense of her midline placement within and lower mandibular teeth tice with extraordinary aes- Nos. 9 and 10 had been re- expectations. We discussed the full facial complex, buc- bleached. Due to the exist- thetic results. Empress is a planted after the endodontic tooth color, her speech pat- cal corridor space, etc, are all ing restorations, of course, lucite-reinforced pressable therapy. Large, prefabricat- tern (especially when she determined. The software the maxillary central inci- glass ceramic with a long, ed posts and porcelain crowns spoke words with F and V also prints out a grid of the sors did not bleach. successful track record. It were present, and when the sounds), and her overall modified Golden Proportion Bleaching is probably provides excellent fit, trans- new radiographs were com- facial appearance. This gave ratio, which you can forward the most requested elective lucency, and vitality, and the pared to an old series, she me an understanding of not to the laboratory in order for dental procedure, and ob- correct brightness value of unfortunately was found to just her personality, but her the dimensions of the teeth taining such nice results the final shade is exclusively DENTISTRY TODAY • DECEMBER 2007
  4. 4. 89 AESTHETICS is a combination of the die which can result from skele- and I could evaluate the aes- helping us properly diag- shade, the ingot material, tal issues and can create a thetics, occlusion, and func- nose each individual case. and the layering material, as canted, unattractive smile. tion of the new smile. She Patient expectations can be well as the staining proce- Note, too, that if the pa- was told to return in one obtained with accuracy via dure and the cementation tient’s head is incorrectly week to discuss how the computers and software, as material that is used. 12 postured, the ceramist may teeth felt, at which time we long as they fit scientifically Studies have also demon- position the incisal edges talked about color mapping into the protocols of our strated strengths between incorrectly. Digital images in terms of the level of original, tested systems. ! Figure 16. Postoperative 1:2 right 160 and 180 MPa.13 of the stick-bite allow the incisal translucency, prob- lateral view. The shade guide chosen ceramist to view the position lems with speech patterns, References 1. Nelson E. Capitalize on the cover- for the final restorations was of the interpupillary/incisal and any other concerns. age. Academy Connection. March/ the Vita 3-D Master system edge position. Once the temporaries were April 2005;3. (Vident). The OM-1 shade Temporaries were fabri- accepted, an impression of 2. Morley J. Smile design terminology. Dent Today. June 1996;15:70. was quite accurate to the cated by using a putty ma- the approved provisionals 3. Dawson PE. Anterior guidance and existing shade seen in Fig- trix that was duplicated was taken for the lab to use its relationship to smile design. In: Functional Occlusion: From TMJ to ure 9, but I wanted to verify from the diagnostic wax-up. in designing the porcelain Smile Design. St Louis, MO: Mosby; that it was as accurate as it Luxatemp shade BL (Zenith/ restorations. The final res- 2007:164-165. 4. Spear F. The maxillary central incisal appeared. While many prac- DMG) was the material of torations were then fabricat- edge: a key to esthetic and function- titioners find it challenging choice, which is a syringable ed and returned to the office al treatment planning. Compend to determine the correct bis-acryl temporary material for evaluation (Figures 11 Contin Educ Dent. 1999;20:512-516. Figure 17. Postoperative 1:2 left 5. Snow SR. Application of the golden lateral view. color, I have had success that is very aesthetic and and 12). percentage in smile design and using the ClearMatch soft- accurate (Figure 10). I chose esthetic treatment success. Con- temp Esthet. Sept 2006. http://www. ware-based system (Clarity to use the indirect method of The End Result Dental), which easily ana- temporary fabrication in For the final restorations, an- s u e s / a r t i c l e s / 2 0 0 6 - 0 9 _ 0 1 . a s p. Accessed November 5, 2007. lyzes color measurement of order to have more control esthesia was administered, 6. Chiche GJ, Pinault A. Esthetics of shade and value with no over embrasure spaces, the and a dry field was obtained Anterior Fixed Prosthodontics. Chi- cago, IL: Quintessence; 1994: 13-14,1. need for proprietary hard- thickness of material, and using the OptraGate system 7. Mechanic E. Smile Design: A Pa- ware. A standardized black marginal fit. Certainly, if I (Ivoclar Vivadent). Patients tient’s Guide. Montreal, Quebec, and white tab, along with a had found thin areas within find the OptraGate more Canada: EC Dental Solutions; 2005: 5-10. specified Classic Vita (Vident) the temporary, I would have comfortable to wear over 8. Ruiz JL. A systematic approach to Figure 18. Postoperative 1:2 shade tab (in this case A2), is performed additional prepa- longer periods of time, as it dento-facial smile evaluation using frontal view. Using the GPS sys- digital photography and a new photo- tem, an evaluation of the final placed adjacent to (incisal ration in those areas. is 3-dimensionally flexible. graphic view. Dent Today. Apr 2006; smile can be seen in Figure 20. edge to incisal edge) an ex- The prepared teeth were The temporaries were re- 25:82-85. 9. Methot A. Get the picture with a GPS isting tooth that is to be scrubbed clean with a chlor- moved, the teeth were redis- for smile design in 3 steps. Spectrum. closely matched. A high-res- hexidine gluconate rinse infected, and water was used 2006;5:100. olution digital image is then (PerioRx [Discus Dental]), to try the veneers in place. 10. Haywood VB. Consideration for vital nightguard tooth bleaching with 10% taken. The ClearMatch soft- and each individual tooth The patient was allowed carbamide peroxide after nearly 20 ware adjusts the hues of the was spot-etched with 35% some time to evaluate how years of proven use. Inside Dentistry. 2006;62-67. image to compensate for any phosphoric acid, followed by they felt before the bonding 11. McLaren EA, Chang YY. Photography color imbalances that may a coating of a desensitizing procedure began. The final and Photoshop: simple tools and rules for effective and accurate com- have occurred while taking agent (Acquaseal [Acqua- results are seen in Figures munication. Inside Dentistry. Oct Figure 19. Postoperative the image. Med Technologies]). Acqu- 13 to 15. Lateral views show 2006;97-102. facial/dental midline evaluation 12. Heffernan MJ, Aquilino SA, Diaz- using GPS. After the color was cho- aseal contains HEMA, which the incisal edge levels, al- Arnold AM, et al. Relative translucen- sen that closely matched the helps seal open dentinal though there was a great cy of six all-ceramic systems. Part I: unprepared teeth, digital tubules, and contains fluo- deal of trauma to the lip core materials. J Prosthet Dent. 2002;88:4-9. photos were taken to aid the ride and benzalkonium chlo- from the automobile acci- 13. McLean JW. Evolution of dental ceramist in closely matching ride, which act as antimicro- dent (Figures 16 to 18). ceramics in the twentieth century [published correction appears in J the teeth color. A new stick- bial agents. Once this mate- Although this was a Prosthet Dent. Apr 2001;85:417]. J bite, face-bow, and CR bite rial is air-dried, a flowable quite difficult case, especial- Prosthet Dent. Jan 2001;85:61-66. 14. Almog D, Sanchez Marin C, Proskin were also taken to assist in composite such as Revo- ly with the loss of natural HM, et al. The effect of esthetic con- mounting the case. lution 2 (Kerr) can be lightly translucency with teeth Nos. sultation methods on acceptance of The stick-bite record helps flowed within the intaglio 9 and 10, the harmonious diastema-closure treatment plan: a pilot study. J Am Dent Assoc. verify any shift in the face- surface of the temporaries. balance we achieved is evi- 2004;135:875-881. bow that could result from Since all bis-acryl materials dent in Figure 19. The final lateral auditory meatus dis- are partly composite and smile reveals a very happy crepancies. If these discrep- partly resin, the flowable patient (Figure 20). Dr. Vastardis maintains an active ancies occur when taking composite binds to the tem- general dental practice in Garden the face-bow, the intercondy- porary itself and strength- CONCLUSION City, NY, with an emphasis on restorative, aesthetic, and implant lar axis could result in a sig- ens it. Only where the teeth Although the protocols we dentistry. He graduated from Tufts nificant change in the func- have been slightly etched use daily in aesthetic dental University School of Dental Medi- tional and aesthetic planes does the temporary/ flowable makeovers have been tested cine and is the founder of the con- of occlusion.14 The incisal combination actually adhere, successfully for many years, sumer educational Web site Floss. Figure 20. Final full facial appear- com. He is a member of the ADA, ance with new smile. edges of the anterior teeth however. When the patient cases that are less than ideal American Academy of Cosmetic should be parallel to the returns for the final seating provide us with special chal- Dentistry, European Society of Es- interpupillary line and per- of the definitive restora- lenges. Extensive planning thetic Dentistry, Nassau County Den- tal Society, Academy of Osseo- determined by the ingot ma- pendicular to the facial mid- tions, the temporaries and and dialogue with the pa- integration, and the International terial. Masking of a dark die line, and the patient’s chin cured flowable material are tient are essential. Hippoc- Academy for Sports Dentistry. He is usually achieved by using must be parallel to the hori- removed with little, if any, rates said, “without diagno- can be reached at (516) 326-0770 an ingot that exhibits both a zon. Use of a miniature level flowable material adhered to sis there can be no treat- or high degree of opacity and gauge for correct alignment the teeth. ment.” Today’s new technolo- low color intensity. The cor- is very helpful in helping to Once the temporaries gies can guide us in obtain- rect final shade of the veneer avoid a skewed incisal plane, were in place, the patient ing the desired results by DECEMBER 2007 • DENTISTRY TODAY