Esthetics in fpd/ oral surgery courses

Esthetics in fixed partialEsthetics in fixed partial
denturedenture
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

Contents:Contents:
IntroductionIntroduction
Light and Color:Light and Color:
-hue-hue
-chroma-chroma
-value-value
Esthetics:Esthetics:
-anatomy of smile-anatomy of smile
-proportion-proportion
-balance-balance
-midline-midline
-an art of illusion-an art of illusion

Esthetics with ceramics:Esthetics with ceramics:
--ceramic laminate veneersceramic laminate veneers
-metal ceramic restorations-metal ceramic restorations
-all ceramic restorations-all ceramic restorations
Shade selection:Shade selection:
-shade selection sequence-shade selection sequence
-shade guides-shade guides
-shade distribution chart-shade distribution chart
Esthetics and Periodontics:Esthetics and Periodontics:
--biologic widthbiologic width
-crown lengthening-crown lengthening
-abnormal frenal attachment.-abnormal frenal attachment.
-pontic design-pontic design
Summary and ConclusionSummary and Conclusion
References.References. www.indiandentalacademy.comwww.indiandentalacademy.com

IntroductionIntroduction
In today's world, looking good is a prime concern .
Appearance is closely linked to social acceptance and
professional success. Newer techniques are being
harnessed for this purpose and advanced research is
being undertaken. Dental art has long been part of the
quest to enhance the esthetics of the teeth and mouth.

The esthetic dentist should have a thorough
knowledge and appreciation of the artistic
principles that can be applied to the dento-facial
complex and should combine artistic creativity
with scientific discretion to effect an appreciable
change in the dentition……

EstheticsEsthetics, from the Greek word “, from the Greek word “aisthesisaisthesis”, meaning”, meaning
perception is the theory of experience basedperception is the theory of experience based
judgment, by which an optical stimulus is not simplyjudgment, by which an optical stimulus is not simply
perceived as an object of consciousness butperceived as an object of consciousness but
evaluated as pleasant or unpleasant, beautiful orevaluated as pleasant or unpleasant, beautiful or
ugly.ugly.

The difficulty with esthetic judgment is thatThe difficulty with esthetic judgment is that
objective criteria is not always decisive, muchobjective criteria is not always decisive, much
depends on the scientific feelings anddepends on the scientific feelings and
interpretation of the observer, with cultural factorsinterpretation of the observer, with cultural factors
playing a significant role.playing a significant role.

Light:Light:
Light is described as visible electromagnetic energy
whose wavelength is measured in parameters or
billionth of a meter.
The most common light source in dental offices are
incandescent and fluorescent; neither of which are
pure white light.

Color:Color:
Color cannot be perceived without light, which is aColor cannot be perceived without light, which is a
form of electromagnetic energy visible to the humanform of electromagnetic energy visible to the human
eye. It has the ability to stimulate the cells in theeye. It has the ability to stimulate the cells in the
retina which is interpreted by the brain, discerningretina which is interpreted by the brain, discerning
the sense of color. Color perception occurs as athe sense of color. Color perception occurs as a
result of the pattern of optical and cerebralresult of the pattern of optical and cerebral
responses over a narrow band of electro-magneticresponses over a narrow band of electro-magnetic
spectrum.spectrum.

In 1915, Albert Henry Munsell, created an
orderly numeric system of color description that
is still the standard today. In this system color is
divided into three parameters:
-Hue
-Chroma
-Value.

HueHue::
Hue is defined “as the particular variety of aHue is defined “as the particular variety of a
color, shade, or tint.” the hue of an object cancolor, shade, or tint.” the hue of an object can
be red, green, yellow, and so on and isbe red, green, yellow, and so on and is
determined by the wavelength of the reflecteddetermined by the wavelength of the reflected
and/or transmitted light observed.and/or transmitted light observed.

The shorter the wavelength the closer the hue
will be to the violet portion of the spectrum,
the longer the wavelength the closer it will be
to the red portion. Hues, used in dentistry,
have a relationship to one another that can be
demonstrated on a color wheel.

ChromaChroma::
-Chroma is defined “ as the intensity of a hue”. The terms-Chroma is defined “ as the intensity of a hue”. The terms
saturation and chroma are used interchangeably which maysaturation and chroma are used interchangeably which may
be defined as the purity or strength of the hue.be defined as the purity or strength of the hue.
-In Munsell color system, maximum chroma depends on the-In Munsell color system, maximum chroma depends on the
particular hue but can range from 10 to 14.particular hue but can range from 10 to 14.
-Pale colors have a low chroma whereas intense colors have-Pale colors have a low chroma whereas intense colors have
high chroma.high chroma.

ValueValue
-Value is defined “ as the relative lightness or-Value is defined “ as the relative lightness or
darkness of a color or the brightness of andarkness of a color or the brightness of an
object.” The brightness of any object is aobject.” The brightness of any object is a
direct consequence of the amount of lightdirect consequence of the amount of light
energy the object reflects or transmits.energy the object reflects or transmits.
-A light tooth has a high value, and a dark-A light tooth has a high value, and a dark
tooth has a low value. Natural teeth range intooth has a low value. Natural teeth range in
value from 5.5 to 8.5 in Munsell method.value from 5.5 to 8.5 in Munsell method.

Metamerism: “The change in color perception of two
objects under different light sources is called
metamerism..” eg: A shade guide tooth matches the
natural tooth under incandescent light but not under
fluorescent light.
Fluorescence : “The emission of light by an object at a
different wavelength from that of the incident light is
called fluorescence.”

OpalescenceOpalescence::
Natural teeth , particularly at their incisal edges ,Natural teeth , particularly at their incisal edges ,
exhibit a light-scattering effect that creates theexhibit a light-scattering effect that creates the
appearance of bluish-white colors as the teeth areappearance of bluish-white colors as the teeth are
seen at different angles.seen at different angles.
This is similar to the bluish-white background seen inThis is similar to the bluish-white background seen in
opal gemstones. This explains the term opalescence.opal gemstones. This explains the term opalescence.

Color blindnessColor blindness::
Defects in color vision affect about 8% of maleDefects in color vision affect about 8% of male
population and less of the female population.population and less of the female population.
Different types exist ,such as achromatism,Different types exist ,such as achromatism,
dichromatism and anomalous trichromatism.dichromatism and anomalous trichromatism.
Dentists should therefore have their color perceptionDentists should therefore have their color perception
tested, and if any deficiency detected then should seektested, and if any deficiency detected then should seek
assistance when selecting shades.assistance when selecting shades.

EstheticsEsthetics::
-Esthetics is the study of the beauty.-Esthetics is the study of the beauty.
A knowledge of esthetics helps the dentistA knowledge of esthetics helps the dentist
achieve a pleasing appearance or effect.achieve a pleasing appearance or effect.
-A successful prosthodontic restoration will-A successful prosthodontic restoration will
Provide the patient with excellent long termProvide the patient with excellent long term
function and will also produce an attractive smile.function and will also produce an attractive smile.

Anatomy of smile:Anatomy of smile:
Most people feel they can recognize an attractive
smile ,but individual opinion will vary, particularly
when cultural factors are considered. In general,
an extensive smile that showed the complete
outline of maxillary anterior teeth and teeth
posterior to the first molar was considered most
attractive and youthful. In smiles that were
considered the most attractive, the incisal edges
of the maxillary teeth were parallel to the lower lip.

ProportionProportion::
-Esthetics depends largely on proportion. An object is
considered beautiful if it is properly proportioned, and is
unattractive if it is top-heavy, squat, or out of proportion.
-Their growth is closely related to mathematical
progression called (Fibonacci series) in which each
number is the sum of two immediately preceding it :
0,1,1,2,3,5,8,13,21,34,55,89, and so on (n1+n2 = n3).

The ratio between succeeding terms converges
approximately 1.618 to 1 known as golden proportion.
When a line is bisected in the golden proportion, the ratio
of smaller section to the larger section is the same as the
ratio of the larger section to the whole line. A harmony
exists in the smile when the golden proportion exists
between the maxillary central incisor and the lateral
incisor as well as the lateral incisor and the canine .

Application of sizing the central incisors from
certain facial measurements is known as 1 to 16
theory, whereby the height of an ideal maxillary
central incisor from the incisal edge to the gingival
crest is 1/16th
of distance from inferior border of the
chin to the inter-pupillary line. The same tooth
width can be measured from the mesial to distal
contact areas and is 1/16th
of the distance
measured from either zygometic prominence
through an imaginary facial midline.

Balance:Balance:
Balance, including the location of the midline is an
important prosthodontic concept. The observer expects
the left and right side of the mouth to balance out, if not
to match precisely.
An obvious restoration on one side may be balanced if
there is a diastema or a large tooth on the other side. A
balanced arrangement implies stability and permanence.

MidlineMidline
-Coincidence of facial and incisal midline is stressed
when assessing orthodontic treatment planning and
should be carefully evaluated when treatment –planning
prosthodontics.
-Studies have shown that mean threshold for acceptable
dental midline deviation is 2.2-1.5 mm.

An art of illusionAn art of illusion

Esthetics with ceramicsEsthetics with ceramics
Evolution of high grade ceramic materials has increasedEvolution of high grade ceramic materials has increased
the possibility of superior results with predictablethe possibility of superior results with predictable
esthetics. However, functional and esthetic benefits canesthetics. However, functional and esthetic benefits can
be maximized using proper preparation design, makingbe maximized using proper preparation design, making
good records and correctly transferring them to thegood records and correctly transferring them to the
technician followed by adequate care in fabricating andtechnician followed by adequate care in fabricating and
cementing the restoration.cementing the restoration.

((A)A) Ceramic laminate veneersCeramic laminate veneers; the subsequent; the subsequent
developments in modern science and toothdevelopments in modern science and tooth
preparation design laid the foundation of thispreparation design laid the foundation of this
modern, extremely esthetic, relatively non-invasivemodern, extremely esthetic, relatively non-invasive
and highly predictable treatment with ceramicand highly predictable treatment with ceramic
laminates. Today, ceramic laminates are anlaminates. Today, ceramic laminates are an
inseparable part of modern day esthetic practice.inseparable part of modern day esthetic practice.

Consideration in tooth preparation for ceramic
laminates:
Tooth preparation will depend on the existing color
of the teeth , whether change in alignment or an
increase in height of the final restoration is sought.
When a mild or moderate discoloration has to be
masked the preparation can be minimal from 0.3mm
cervically to 0.5mm at the incisal edge.

When more severe discoloration is to be masked theWhen more severe discoloration is to be masked the
preparation has to be deeper to allow more die spacer topreparation has to be deeper to allow more die spacer to
be applied on the model. Adding more opaque ceramic inbe applied on the model. Adding more opaque ceramic in
the veneer will mask undesirable tooth color but willthe veneer will mask undesirable tooth color but will
limit the display of vitality.limit the display of vitality.

(B) Metal ceramic restoration; metal ceramic have an
excellent esthetic potential. The metal ceramic owe
their popularity to the simplicity of bridge
construction, durability, strength, marginal adaptation
and versatility of use. It can be used successfully for
various complex clinical situations like long span
bridges, full mouth rehabilitation.

The trial can be done at every stage of fabrication , thusThe trial can be done at every stage of fabrication , thus
reducing the possibility of repeats.reducing the possibility of repeats.
Although all anterior teeth where esthetics is a primeAlthough all anterior teeth where esthetics is a prime
concern can be indicated for all ceramic restorations ,concern can be indicated for all ceramic restorations ,
caution has to be taken where a para-function exists,caution has to be taken where a para-function exists,
when tooth structure is insufficient to support thewhen tooth structure is insufficient to support the
ceramic in short clinical crowns and when the lingualceramic in short clinical crowns and when the lingual
preparation is thinner than 0.8mm. In such cases a metalpreparation is thinner than 0.8mm. In such cases a metal
ceramic restoration is functionally stable and indicated.ceramic restoration is functionally stable and indicated.

(C)(C) All ceramic restorationsAll ceramic restorations; all ceramic restorations are; all ceramic restorations are
characterized with a dentin like core which makes itcharacterized with a dentin like core which makes it
possible to mimic the translucency of natural teeth.possible to mimic the translucency of natural teeth.
They are bio-compatible with the gingival tissues andThey are bio-compatible with the gingival tissues and
exhibit excellent marginal fit. They are indicated forexhibit excellent marginal fit. They are indicated for
crowns,veneers, inlays, on lays and three unit bridgescrowns,veneers, inlays, on lays and three unit bridges
with the premolar as the distal-most abutment. Thesewith the premolar as the distal-most abutment. These
can be even bonded to teeth giving additional retention.can be even bonded to teeth giving additional retention.

The main concern of the dentist in the preparation of allThe main concern of the dentist in the preparation of all
ceramic crowns should be to minimize the stresses thatceramic crowns should be to minimize the stresses that
could be incorporated on the ceramic in function. Thecould be incorporated on the ceramic in function. The
thickness of the ceramic itself does not make thethickness of the ceramic itself does not make the
restoration strong but it is the support from a properrestoration strong but it is the support from a proper
preparation and the fit of the restoration which gives itpreparation and the fit of the restoration which gives it
the required strength.the required strength.

Shade selection:Shade selection:
To provide the patient with esthetic restoration ,the
dentist must consider the scientific basis of color as well
as the artistic aspects of the shade selection.
Considerable variation exists among dentists, some
dentists are unable to duplicate even their own shade
selection from one patient to the next. Shade selection
can be improved by applying the principle of light and
color and dental ceramics techniques.

Shade selection sequence:Shade selection sequence:
There are few simple guide lines to be followed by
practitioners;
-Use the shade guide that matches the porcelain your
technician is using.
-The shade should be matched prior to preparation of the
tooth to be restored.
-Ask the patient to remove all distractions before
attempting to match a shade, such as lipstick, earings,
glasses, and heavy facial makeup.

-Be sure that the teeth are clean and unstained before-Be sure that the teeth are clean and unstained before
attempting to match a shade.attempting to match a shade.
-Seat the patient in an upright position with mouth at-Seat the patient in an upright position with mouth at
operators eye level.operators eye level.
-Observation should be made quickly (5 seconds or less)-Observation should be made quickly (5 seconds or less)
to avoid fatiguing the cones in retina.to avoid fatiguing the cones in retina.
-The shade should be matched by value, chroma and hue-The shade should be matched by value, chroma and hue
in that order.in that order.
-When in doubt about two tabs, hold them side by side-When in doubt about two tabs, hold them side by side
on the tooth to be matched and compare to get the fineston the tooth to be matched and compare to get the finest
match.match.

-Shade tabs of different batches don’t always match-Shade tabs of different batches don’t always match
hence it is wise to send the actual selected shade tab tohence it is wise to send the actual selected shade tab to
the technician.the technician.
-If possible, take photographs with shade tabs in place.-If possible, take photographs with shade tabs in place.

Shade guide:Shade guide:
-The dentist can avail of subjective or objective
methods of shade selection.
-The subjective method towards obtaining an
optimum result is most widely accepted and
used. The most popular and commonly used
shade guides are Vitapan classical, Ivoclar
chromascope and Vitapan 3D shade master.

-Digital shade analysis eliminates the subjective of color-Digital shade analysis eliminates the subjective of color
analysis and provides exact information for laboratoryanalysis and provides exact information for laboratory
fabrication of the prosthesis. The influence is morefabrication of the prosthesis. The influence is more
objective, can be repeatedly verified and involves lessobjective, can be repeatedly verified and involves less
chair-side time.chair-side time.
-Thus, in spite of certain drawbacks, technology based-Thus, in spite of certain drawbacks, technology based
shade guide systems hold a promising future in helpingshade guide systems hold a promising future in helping
to mimic nature to the fullest.to mimic nature to the fullest.

Vitapan 3D master shade guide:Vitapan 3D master shade guide:
The shade samples are grouped in six light
variation in evenly spaced steps. The shade
guide is spaced in steps of 4 CIELAB units in
lightness dimension and 2 CIELAB units in the
hue & chroma dimensions. The manufacturer
recommends selecting the lightness level first
with this system and then selecting the chroma
or saturation and finally the hue.

Shade distribution chart:Shade distribution chart:
Shade distribution charting is a practical approach
to accurate shade selection and is recommended
even when a fairly good match is available from
the commercial shade sample. The tooth is
divided into three region: cervical, middle and
incisal. Each region is matched independently
either to the corresponding area of a commercial
shade sample or to a single color porcelain chip.
Because only single color is matched intermediate
shades can

usually be estimated rather easily and duplicatedusually be estimated rather easily and duplicated
by mixing porcelain powders. The junctionby mixing porcelain powders. The junction
between these areas are normally distinct and canbetween these areas are normally distinct and can
be communicated to the laboratory in the form of abe communicated to the laboratory in the form of a
diagram. Individual characteristics are marked ondiagram. Individual characteristics are marked on
such a sketch and will allow the ceramist to mimicsuch a sketch and will allow the ceramist to mimic
details like hair-line fractures, hypo calcificationdetails like hair-line fractures, hypo calcification
and proximal discolorations.and proximal discolorations.

Esthetics and Periodontics:Esthetics and Periodontics:
Periodontal therapy plays an important role in
esthetics through the introduction of new surgical
techniques and the adaptation of traditional
periodontal procedures. In addition, the recognition
of the etiology and complicating factors underlying an
esthetic periodontal problem is crucial .
The periodontal defects posing an esthetic problem
can be addressed once the patient is adequately
motivated in periodontal health, maintenance and
efficient plaque control.

These defects may include:These defects may include:
1) Violation of biological width.
2) Gingival asymmetries
3) Abnormal frena
4) Excessive gingival display.
5) Deficient pontic areas.

Biologic width:Biologic width:
Interference drawn from autopsy recording suggests that
the mean sulcus depth is 0.69mm, mean length of
junctional epithelium is 0.97mm and connective tissue
attachment is 1.07mm. The combined width of the latter
two is 2.04mm and is referred to as biologic width. This
biologic width is always maintained between the tooth
and periodontal apparatus, violation of which would lead
to gingival inflammation and bleeding resulting in
recession and/or pocket formation.

Crown lengthening:Crown lengthening:
In cases of single tooth gingival asymmetry
where crown lengthening with minimal osseous
reduction is indicated, where in after the
gingivectomy is carried out, two vertical
incisions are made on the gingival margins
without involving the interdental papilla .
After the raising the flap the osseous reduction is
carried out. While contouring the bone, care
should be taken to avoid any ledge formation in
the bone crest.

Abnormal frenal attachment:Abnormal frenal attachment:
The maxillary frenum may cause esthetic problems,
especially in cases of gingival smiles. The frenum can
also cause a pulling force on the gingival margin, in
some cases leading to gingival inflammation and
progressive recession of gingiva.
A resection (frenectomy) or a repositioning
(frenotomy) may be necessary. When the esthetics is
the only factor then a frenotomy may be necessary to
give the desired result.

Pontic design:Pontic design:
Pontics are the artificial teeth of a fixed partial denture
that replace missing natural teeth restoring function and
appearance. The pontic as it mechanically unites the
abutment teeth and covers a portion of the residual ridge,
assumes a dynamic role as a component of the prosthesis
and cannot be considered as a life less insert of gold,
porcelain or acrylic.

Residual ridge contour:Residual ridge contour:
An ideally shaped ridge has a smooth, regular surface of
attached gingiva , which facilitates maintenance of
plaque free environment . Its height and width should
allow placement of a pontic that appears to emerge from
the ridge and mimics the appearance of the neighboring
teeth. Loss of residual ridge contour lead to unaesthetic
open gingival embrasures, food impaction and
percolation of saliva during speech.

Siebert classified residual ridge deformities into three
categories.
Class 1 : Facio lingual loss of tissue width with normal
ridge height.
Class2 : Loss of ridge height with normal ridge width.
Class3 : A combination of loss in both dimension.

Prosthetic gingiva:
When interdental spaces are of concern and no cosmetic
prosthetic work is anticipated, artificial gingiva is an
option. A border molded impression is made of the
involved area. The laboratory fabricates a gingival
veneer of pink denture acrylic, with the apical extent in
the mucobucal fold and the coronal extent restoring a
normal free gingival margin appearance.

SummarySummary

ReferencesReferences

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Esthetics in fpd/ oral surgery courses

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