Music Universal Language Communication Smile · aesthetic restoration with diagnostic planning”...

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Music

Universal Language

♪♫♪♫♪♫

Smile

Universal Language Communication

Emotions

“The smile is a way of expressing on the outside our feelings on the inside”

Equally Qualified

Congratulations,

You’re hired!

Communication: Success

Excess Gingival Display

Excessive gingival display negatively affected how attractive a person's smile is judged to be. In addition, how friendly, trustworthy, intelligent, and self-confident a person was perceived to be was inversely related to the amount of gingival display. Laypeople were just as sensitive to these differences as dental students.

Communication: Perception

Malkinson S1, Waldrop TC, Gunsolley JC, Lanning SK, Sabatini R. The effect of esthetic crown lengthening on perceptions of a patient's attractiveness, friendliness, trustworthiness, intelligence, and self-confidence. J Periodontol. 2013 ;84:1126-33.

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Plain looking individuals made 5-10% less per year

A ttractive persons made 4-8% more per year(based on their own personal opinion of their appearance)

In 2014:

Median US household yearly

salary was

$53,891*

According to a recent survey:

*Sentier Research Group as cited http://money.cnn.com/2014/08/20/news/economy/median-income/

Why Do People Seek Cosmetic Dentistry?

AACD Survey 2013

Smile

Dr Guillaume Duchenne

Guillaume-Benjamin Duchenne de Boulogne“Mechanism of Human Physiognomy or Electro-physiological Analysis of the Expression of the Passions ”

• 1840’s Paris physician• Muscles contract into facial

expressions• First to demonstrate

mechanism of smiling

What is a Smile?

Dr Guillaume Duchenne

“Smiling constitutes a universal language which neither fashions nor whims can change …and is the same in all people…”

Guillaume-Benjamin Duchenne de Boulogne“Mechanism of Human Physiognomy or Electro-physiological Analysis of the Expression of the Passions ”

Smile Muscles

Muscles of Facial Expression

• Zygomatic• Buccinator• Obicularis Oris• Triangularis

Plastic Surgery without a Scalpel

“The muscles of facial expression

must be supported to allow proper

smiling.”

Dr. Irwin Smigel

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What is a Smile?

“…The smile offers a convenient shorthand for far-reaching assessments of character, behavior, and temperament. ” 2004 Angus Trumble “A Brief

History of the Smile ”

Angus Trimble

What is a Smile?

Richard Conniff

Smithsonian 2007“What’s behind a Smile?”

“Our facial expressions, and especially the smile, constitute a system of unconscious communication that got built into our biology long before language itself”

What is a Smile?

“Smiles in fact are the most visible part of an intimate melding between two minds”

New York Times 2011FACIAL TRIANGLE

Smiles are part of the FACE

Facially Generated Dental Esthetics

Multi-disciplinary Approach

• Orthodontics• Periodontics• Prosthodontics• Facial Plastic

Surgeon

Dr. David Sarver

Introduction to Smile Design

•There are rules•Rules are made to be

broken•No one smile ever

follows all the rules

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•Let’s start with a blank canvas

•Where do we begin?

Designing an Ideal Smile

Incisal edge is starting point!

•Incisal plane parallel to the interpupillaryline

Incisal Placement

Canted Incisal Plane

•Forehead - from Trichion to Nasion

•Cheek - Nasion to Subnasale

•Mouth - Subnasaleto Menton

Trichion

Nasion

Subnasale

Menton

Rule of Thirds

•Divide subnasale and menton into equal Thirds

•Incisal edge at junction of Superior and Middle Thirds

Incisal Edge

Rule of Thirds Incisal Plane too inferior

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Incisal Plane too superior

•Appearance

Determinents of Incisal Edge Placement:

•Appearance•Phonetics

Determinents of Incisal Edge Placement:

Use words like “these, those, fifty five, very fine”

Pound- JPD 1970“Using speech to simplify

denture service”

“When the patient pronounces “f” and “v”sounds…the length and labiolingual position of the incisal edges of the maxillary teeth…can be determined.”

Incisal Edge Position:Phonetics

•Appearance•Phonetics•Occlusion

Determinants of Incisal Plane Placement:

•Vertical midline in the center of the face perpendicular to the interpupillary line

•Vertical midline centered with the philtum

Incisal Placement

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Smile CurveReverse Smile Curve

•Incisal edges follow curvature of the lower lip

Incisal Placement

The anterior-posterior curvature of the occlusal plane superiorly as you move distally

Curve of Spee Curve of Spee-Flat

•Clinical crown outlined by the upper and lower lip

•Marginal gingiva display confined to interdental papilla

Tooth Display

•Altered Passive Eruption

Excess Gingival Display

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Altered Passive Eruption

•12%-15% of patients exhibit altered passive eruption•May persist into the late teens and mid 20’s•A predisposing factor to ANUG

•Prevalence

Weinbert MA, Eskow RN. An Overview of Delayed Passive Eruption. Compend. 2000;21:511-520.


• Prevalence of Altered Passive Eruption (APE) is higher after Orthodontic Treatment

• APE is more common in individuals with a thick-flat gingival biotype

•Role of Orthodontics

Nart J, Carrió N, Valles C, Solís-Moreno C, Nart M, Reñé R, Esquinas C, Puigdollers Prevalence of altered passive eruption in orthodontically treated and untreated patients. J Periodontol. 2014; 85(11):348-53.



Type Ia Excessive keratinized tissue & normal CEJ-alveolar crest relationship-GingivectomyType Ib Excessive keratinized tissue & alveolar crest at CEJ-Flap Periodontal SurgeryType IIa Normal keratinized tissue & normal CEJ-alveolar crest relationship-OrthognathicSurgery or OrthodonticsType IIb Normal keratinized tissue & alveolar crest at CEJ-Flap Periodontal Surgery

•Diagnostic Type



Diagnostic Tools•Radiographs•Anesthetize and sound to CEJ•Determine if osseous contouring needed (biologic width=3mm)•Flap vs flapless

Surgical Armementarium•Diode Laser vs Erbium-based Laser•Scalpel•Electrosurgery

Altered Passive EruptionCase Presentation

•Post-Orthodontics

•Type 1b

Altered Passive EruptionCase Presentation

•Post-Perio Surgery

•Final Treatment after Tooth Whitening

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•Buccal Corridor•Negative Space

Smile Display

•Display of posterior buccal teeth

Smile DisplayFilling the Buccal Corridor

•Black Triangles

•Opaque Crowns-margins

•Centrals slightly too long


Smile Template

•Black Triangles

•Opaque Crowns-margins

•Centrals slightly too long

•Build out posterior teeth

•Curve of Spee


•Teeth Prepared

•Provisionals fabricated

•Creating desired shape in provisionals

•Patient acceptance


•Send photos and impressions of provisionals to lab

•Tryin and seat crowns

Roots diverge apically as you move distally-anteriors

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Roots converge apically as you move distally-anteriors

Incisal embrasures become larger as you move distally

Roots diverge apically as you move distallyContact points move apically as you move distally

Roots diverge apically as you move distallyConnector Area

Morley J –Prac Perio Aesth Dent 2000 “A multidisciplinary approach to complex

aesthetic restoration with diagnostic planning”

50%

40%

30%

•Connector area is the perceived area where the two teeth appear to touch•Percentage is of height of tooth•Contact point is usually 2mm or less

Apical Zenith located distal to the long axis midline

Roots diverge apically as you move distallyCervical of Central Incisors and Cuspids are parallel

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Roots diverge apically as you move distallyIncisal and cervical length of laterals may be 0.5-1mm shorter than Central Incisor

Feminine

Roots diverge apically as you move distallyIncisal and cervical length of laterals may be 0.5-1mm shorter than Central Incisor

Masculine

•Central Incisor:DOMINANCE

•Lateral Incisor:VARIABILITY

•Cuspid:AGGRESIVENESS

Factors affecting each tooth in the smile

Morley – Dentistry Today 1990“Design Theory of Central

Incisors”

Central IncisorsMirror Images

Frush & Fisher - JPD 1957“The Age Factor in Dentogenics”

Central IncisorsSPA factor-Age

Roots diverge apically as you move distallyCompensate for Discrepancies by Creating Illusions-Width

Narrow Wide

NarrowWide

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Roots diverge apically as you move distallyCompensate for Discrepancies by Creating Illusions-Height

Curved

Flat

(Short)

(Tall)

Lateral Incisors-Diversity SPA Factor Sex

Frush & Fisher - JPD 1956“How Dentogenic Restorations

Interpret the Sex Factor”

MasculineFeminine

Masculine Feminine

Roots diverge apically as you move distallyMasculine vs feminine

Feminine

•Rounded facial profile

•Shorter lateral incisor

•Apical zenith-lateral centered

•Narrow gingival width of LI

•Rounded incisal forms

Lombardi - JPD 1973“The principles of visual

perception and their clinical application to denture esthetics”

Research show no difference in extracted teeth from male

to female;

However

Masculine vs feminine

FeminineMasculine

Cuspids-AggresivenessSPA Factor-Personality

Frush & Fisher - JPD 1956“How Dentogenics Interprets the

Personality Factor”

AggressivePassive

Smile DesignBENDING the rules

•Age•Face Form•Personality•Proportions

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Every smile looks the same (dentist, orthodontist or dental lab “trademark smile”

•May not be age appropriate

•May not coincide with the physical and emotional makeup of the patient

•Size may not match size and shape of face

Roots diverge apically as you move distallyCookie Cutter SmilesSmiles are too Perfect!

Roots diverge apically as you move distallyCreating a Younger Smile

•Textured incisal edges

•Pronounced incisal embrasures

•Mammelons, developmental grooves, perikymata, lines of Retzius

•Prominent maxillary teeth display

•Increased value, Hunter-Schregerbands, incisal translucency

Morley J. The Role of Cosmetic Dentistry in Restoring a Youthful Appearance. JADA

1999; 130:1166-1172.

Roots diverge apically as you move distallyNatural Aging of the Face

•Modified Rule of ThirdsPowell N, Humphreys B. Proportions of the Aesthetic Face.

New York. Thieme-Stratton, 1984.

Roots diverge apically as you move distallyNatural Aging of a Smile

•Flattened, worn incisal edges

•Smaller incisal embrasures

•Smoother facial anatomy

•Display-mandibular teeth

•Increased chroma

•Anterior Splaying

Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978; 39:502-

504.

Roots diverge apically as you move distallyRelationship of Face Form and Tooth Form

Denture teeth often recommend tooth form to mimic face form

Roots diverge apically as you move distallySmile Shapes

by Dr Bill Dickerson

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Smile Shapes

From “The Smile Catalog”

TM The Ultimate Practice Inc

Smile Shapes

From “The Smile Catalog”

TM The Ultimate Practice Inc

Dr.Galip Gurel

Correlating Face and Personality

• Dynamic• Delicate• Stabile

Relationship of Personality and Tooth Form

•Flat incisal plane

•Rectangular central incisors-square FGM

•Larger masculine lateral incisors

•Straight canine profile

•Straight across apical zeniths

•Flattened Curve of Spee

Roots diverge apically as you move distallySmile DesignBold

70% RED Proportion

78% W/L Ratio

•V-Shaped incisal plane

•Large square tapering central incisors

•Smaller lateral incisors

•Cervical of aggressive canines out

•Ascending apical zeniths

•Steep Curve of Spee

Roots diverge apically as you move distallySmile DesignDynamic

Golden Proportion

78% W/L Ratio

•Curved incisal plane

•Oval central incisors

•Oval feminine lateral incisors

•Oval canine profile

•Oval apical zeniths

•Normal Curve of Spee

Roots diverge apically as you move distallySmile DesignSerene

75% RED Proportion

78% W/L Ratio

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•Square central incisor

•Lateral incisor more similar in size to central

•Perpendicular passive canines with curved profile

•Slightly curved apical zeniths


Roots diverge apically as you move distallySmile DesignPassive

80% RED Proportion

86% W/L Ratio


•Rectangular central incisors

•70% RED lateral incisors



•Curve of Spee

Roots diverge apically as you move distally

70% RED Proportion

78% W/L Ratio

Smile DesignPerfect

•Straight incisal plane

•Natural-looking central incisors

•66% RED lateral incisors

•Canine cervicals out

•Shorter lateral apical zeniths

•Slight Curve of Spee


Natural width Proportion

78% W/L Ratio

Smile DesignNatural


•Rectangular central incisors-square FGM

•Larger masculine lateral incisors





70% RED Proportion

78% W/L Ratio

Smile DesignBold

•V-Shaped incisal plane

•Large square tapering central incisors

•Smaller lateral incisors

•Cervical of aggressive canines out


•Steep Curve of Spee


Golden Proportion

78% W/L Ratio

Smile DesignDynamic


•Oval central incisors

•Oval feminine lateral incisors

•Oval canine profile

•Oval apical zeniths

•Normal Curve of Spee


75% RED Proportion

78% W/L Ratio

Smile DesignSerene

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•Square central incisor

•Lateral incisor more similar in size to central

•Perpendicular passive canines with curved profile

•Slightly curved apical zeniths


Roots diverge apically as you move distallySmile DesignPassive

80% RED Proportion

86% W/L Ratio

•Uneven incisal plane

•Shovel-shaped central incisors

•Twisted lateral incisor

•Cervical in and cervical out canine profiles


•Flat Curve of Spee


70% RED Proportion

86% W/L Ratio

Smile DesignImperfect/Passive

Angelina Jolie Traditional Dentistry

• Teeth• Periodontium• Occlusion• Periodontal

Architecture

Traditional Dentistry Components

• Visual Exam• Tactile Exam• Diagnostic Casts• Radiographs

Objective Tooth Evaluation

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Cosmetic Dentistry

• Teeth• Periodontium• Occlusion• Periodontal

Architecture• Lips • Facial Muscles• Skeletal structure• Soul

Cosmetic Dentistry Components

Subjective Smile Evaluation

TLAR Principle

Evaluation Methods

Objective Smile Evaluation

Proportional Smile Design

Evaluation Methods


Evaluation Methods

Chair-side Smile Evaluation

Evaluate this smile

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Evaluation Methods

Diagnostic Casts Evaluation


LaboratoryWaxup

• Lips • Facial Muscles• Skeletal structure• Soul

Diagnostic Casts?

• Evaluate all smile components

• Unlimited Time Factor

• Measure relative tooth dimensions

• Predictable Results

CHALLENGE



PredictableCosmetic DentistryCannot be

achieved without the use of: PHOTOGRAPHY

Using Photographyto

Design Smiles

“My wife wants me to do a smile makeover”

Using Photographyto

Design Smiles

“I just don’t like the gray spots. I want whiter teeth!”

Using Photographyto

Design Smiles

High Occlusion

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Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Lingual composites # 9 & #11

“I just don’t like the gray spots. I want whiter teeth!”

Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Crowns # 9 & #11

Using Photographyto

Design Smiles

Treatment Options

Implant # 10

Crowns # 9 & #11

Using Photographyto

Design Smiles

Challenges

Replace missing tooth

Change cant

Whiten smile

Using Photographyto

Design Smiles

Ideal Design

•All-porcelain bridge#9-11•Porcelain laminateveneers #5,6-8,12

Using Photographyto

Design Smiles

Recommended Treatment

•All-porcelain bridge#9-11•Porcelain laminateveneers #5,6-8,12

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Using Photographyto

Design Smiles

Accepted Treatment

•All-porcelain bridge#9-11•Porcelain laminateveneers #6-8

Using Photographyto

Design Smiles

Preparations

Using Photographyto

Design Smiles

Seating

Soft Tissue Model

Using Photographyto

Design Smiles

Completed Case

Music Universal Language Communication Smile · aesthetic restoration with diagnostic planning”...

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