GETTING THE PERFECT SMILE

Written and presented by

Frank C. Stone, D.D.S.


 

Copyright 2017 Frank C. Stone, III D.D.S.

All Rights Reserved


 

HOW TO USE THIS BOOK:

Match your interest with the following sections to develop either an overall understanding of Esthetic and Functional Dentistry or specific elements.

Develop a complete understanding of Esthetic and Functional Dentistry and be able to communicate effectively with your Esthetic Dentist and your Plastic Surgeon.

Understand the dynamics of Smile Design

Understand the essentials of building a beautiful smile that will last a lifetime

Understand how to evaluate a smile

Understand how to put the steps together

Choosing the right Esthetic Dentist for YOU

This book represents a behind the scenes investigation of Cosmetic and Esthetic Dentistry and is intended to help you better understand your smile.
You may contact me at:

 frankcstonedds@stonesmiles.com

Yours for a gorgeous smile and optimum dental health,

Frank C. Stone, D.D.S.

 


TABLE OF CONTENTS

GETTING THE PERFECT SMILE

HOW TO USE THIS BOOK:

TABLE OF CONTENTS

INTRODUCTION

THE EVOLUTION OF ESTHETIC DENTISTRY: A 38-YEAR PERSPECTIVE.

THE AGE OF COSMETIC DENTISTRY

PORCELAIN-LAMINATED VENEER RESTORATIONS

THE ROLE OF OCCLUSION AND ESTHETIC DENTISTRY:

LAWS OF ATTRACTION

THE BEAUTIFUL SMILE

THE BROKEN SMILE

THE “BEAUTY RESPONSE”

THE LAWS OF INTERACTION and  COLLABORATION

THE PHYSICS

THE PLAYERS:  DENTIST-DENTAL CLIENT-DENTAL CERAMIST

THE ESTHETIC DENTIST

THE ESTHETIC DENTAL CLIENT

THE FS-SYSTEM

THE ESTHETIC DENTAL CERAMIST

LAWS OF THE ESTHETIC

THE NATURAL ESTHETIC

THE DENTAL ESTHETIC

LAWS OF DENTAL FUNCTION

TEETH IN FUNCTION

THE DESIGN OF TEETH

THE DESIGN OF OCCLUSION (BITE) AND JAW JOINTS

LAWS OF EVALUATION

THE PORTRAIT: THE LIVING SCULPTURE

SMILE DESIGN

OUR THEME: THE FACE

ELEMENTS OF A SMILE

THE SIZE AND SHAPE OF THE FACE

LANDMARKS OF THE FACE

SIZE AND SHAPE OF THE CENTRAL INCISORS

CENTRAL INCISORS

TOOTH SIZE AND THE GOLDEN PROPORTION

GUMLINE SYMMETRY WITH UPPER LIP

A BROAD AND WIDE SMILE

TOOTH PLACEMENT

AXIAL ANGULATIONS OF THE TEETH

TOOTH-TO-TOOTH CONTACTS AND HEIGHT OF PAPILLA

ZENITH POSITIONS

TOOTH SILHOUETTES

THE EMBRASSURE FORMS

COLOR AND INTERNAL CHARACTERIZATIONS

THE BEAUTIFUL SMILE VS. THE STUNNING SMILE

LAWS OF ACTION

PERSONAL SMILE EVALUATION

COSMETIC DENTAL PROBLEMS AND SOLUTIONS

CATEGORIES OF COSMETIC//ESTHETIC DENTAL THERAPIES

COSMETIC DENTAL THERAPIES

(MINOR COMPLEXITY)

SMILE ENHANCEMENT: DISCOLORED TEETH

SMILE ENHANCEMENT: SHORT TEETH

SMILE ENHANCEMENT: FLARED TEETH

INSTANT ORTHODONTICS: CROOKED TEETH

ESTHETIC DENTAL THERAPIES

(ADVANCED COMPLEXITY)

INSTANT ORTHODONTIC SMILE ENHANCEMENT

SMILE RESTORATION: BROKEN TEETH

SMILE RESTORATION: MISSING TEETH (CONGENITAL)

SMILE RESTORATION: MISSING TEETH

SMILE MAKEOVER: COLOR AND SHAPE

SMILE MAKEOVER: LOP-SIDED SMILE

SMILE MAKEOVER: GRIMACING SMILE

SMILE REJUVENATION: CALICO TEETH, WORN AND FLATTENED TEETH ON LOWERS

SMILE REJUVENATION: STAINED TEETH, CROOKED TEETH

SMILE REJUVENATION: SHORT TEETH, FAILING CROWN POSTS, GUMMY SMILE

SMILE REJUVENATION: FLARED BUCK TEETH, STAINED TEETH, CROOKED TEETH, SHORT TEETH

PLASTIC SURGERY AND COSMETIC SURGICAL ENHANCEMNENTS

ESTHETIC//PLASTIC PROCEDURES

ORTHODONTIC-GNATHIC SURGERY

LAWS OF SELECTION

CHOOSING AN ESTHETIC//COSMETIC DENTIST

COSTS AND TIMING

HOME WHITENING

TREATMENT TIME:

PATIENT MAINTENANCE:

RESULTS OF TREATMENT:

RANGE OF LIFE EXPECTANCY:

COST:

ADVANTAGES:

DISADVANTAGES:

COMPOSITE RESIN BONDING

TREATMENT TIME:

PATIENT MAINTENANCE:

RESULTS OF TREATMENT:

AVERAGE RANGE OF TREATMENT LIFE:

COST:

ADVANTAGES:

DISADVANTAGES:

PORCELAIN VENEERS - LAMINATED VENEERS

TREATMENT TIME:

PATIENT MAINTENANCE:

RESULTS OF TREATMENT:

AVERAGE RANGE OF TREATMENT LIFE:

COST:

ADVANTAGES:

DISADVANTAGES:

ALL CERAMIC CROWNS

TREATMENT TIME:

PATIENT MAINTENANCE:

TREATMENT RESULTS:

AVERAGE RANGE OF TREATMENT LIFE:

COST:

ADVANTAGES:

BEST MAINTENANCE ADVICE

REFERENCES

 


 

INTRODUCTION

THE EVOLUTION OF ESTHETIC DENTISTRY:
A 38-YEAR PERSPECTIVE.

1975 Was A Pivotal Year in Dentistry

 

Of all the many phenomenal advancements in dentistry that I have both witnessed and experienced in the past thirty-eight years, one innovation that appeared in 1975 stands out from the pack: That was “resin-enamel-bonding”. This concept of directly attaching composite-resin to the tooth enamel created a paradigm shift that challenged and ultimately changed long established principles of restorative dentistry leading us toward metal free dentistry and more and more into the realm of natural, tooth-like restorations.


 

THE AGE OF COSMETIC DENTISTRY

Our early bonding attempts challenged our skills in that we had to change many established techniques: suffice it to say, there  was an elongated learning curve. Over time we gradually gained confidence with what we generically called “bonding”, so that, by 1982 we were routinely restoring smiles with this revolutionary technique. As long as we bonded to enamel we were confident that the restoration would last 4-6 years; however, when we needed to bond to the soft part of the tooth called dentin, we were much less confident since the strength of the dentin-resin bond was much weaker. We felt that bonding was a “cover-up” and therefore a temporary solution since we did not have a lengthy track record nor did we have confidence with dentin bonding.

We chose “cosmetic bonding” ” to describe these procedures, since we felt that their permanence could be judged along with other cosmetic applications of products, such as, makeup, hairstyling and manicured fingernails: products and procedures that require continuing maintenance. Nonetheless, the cosmetic results were dazzling especially when we bonded to cover superficial blemishes and stains, closed spaces and gaps between teeth and repaired broken edges. We were in the midst of a revolution in dentistry, so much so, that we referred to this new era as “The Age of Cosmetic Dentistry”.


 

PORCELAIN VENEER RESTORATIONS

 

The next advancement came along in the early 1980’s with the introduction of laboratory fabricated, layered porcelain restorations that we bonded to enamel with resin cement. The technique was borrowed from the industrial model of laminate-veneering or joining thin structures together with cements where the laminated product possesses greater strength and beauty than each individual object. We were excited about the overall appearance and esthetic of the completed restorations as the veneers allowed us to change colors of teeth and create a much more lifelike and natural result when compared to bonding. However, we still relied on the enamel-resin bond and in many cases we needed to bond to dentin. The increased strength of the enamel-resin-porcelain laminate (now called “Porcelain Veneers”) encouraged us to think they could hopefully last longer than 4-6 years. Time would tell!

As we gained experience with veneers we also gained confidence. It was very exciting to witness the transformation of the smiles that took place for many of our cosmetic patients and often we would  “push the envelope” of the veneers’ inherent  strength by lengthening the edges of the front teeth to gain even more beautiful teeth as well as restoring back teeth by building biting and chewing surfaces. Time went by and our restorations were still looking good and by 1988 we were routinely restoring the front teeth and the biting surfaces of the back teeth with porcelain bonded restorations including inlays, full crowns and porcelain veneers.

Our excitement was tempered, however, when by 1990 we started to see some early restorations fail either due to the fracture of the veneer or by the veneer “de-bonding” or popping off of the tooth.  In both cases we thought those most likely needed stronger porcelains and more adhesive dentin-bonding resins. Also, we observed cracking and chipping of the edges of the front teeth, some breakage and chipping of porcelain inlays—obviously the effects of wear and tear or the result of the damaging effects of teeth grinding.

As a consequence, we were reminded of the importance of the inter-relationship of the grinding function of the back teeth, the opening and sliding movements of the jaw joints and the position and function of the front teeth: In other words, we needed to establish and integrate a comprehensive esthetic- restorative treatment model that would make sure that these three systems were functioning in harmony.


 

THE ROLE OF OCCLUSION AND ESTHETIC DENTISTRY

 

The unification of Cosmetic Dentistry with the advanced principles of dentistry called Occlusion (“treatments that involve reconstruction of the edges of the front teeth with the chewing surfaces of the back teeth in direct harmony with the jaw joints and height of the face”) allowed us to establish a comprehensive, esthetic and functional dental model that would allow us to obtain predictable results for our Cosmetic and Esthetic dental treatments.

With the introduction of this model, whereby all esthetic and cosmetic dental restorations were coordinated with the movements of the back teeth and jaw joints, our success skyrocketed and our failures dropped dramatically.  In fact, during the twenty-five-year period from 1991 thru 2016, 98% of all porcelain- bonded- restorations that I have completed remain intact, in function and continue to provide my dental clients exceptional lifelike restorations.

As dental materials continue to improve with respect to appearance and strength, I expect to see an even higher degree of successes. As such, these Porcelain Bonded Restorations, such as, porcelain veneers, porcelain inlays and all porcelain crowns are no longer just a cosmetic cover-up: They truly can be regarded as long term Esthetic and Functional Restorations.


 

LAWS OF ATTRACTION

THE BEAUTIFUL SMILE

We all do it!  We stare boldly at a beautiful face, somehow unable to pull our eyes away. It seems as if a mysterious force has magnetized our very soul to this object and we feel an involuntary attraction...  We finally look away embarrassed by our reaction and wonder to ourselves, “what power compels us to act this way?”


 

THE BROKEN SMILE

Other situations abound where we are hopelessly seduced (and sometimes repelled) by this “force of nature”.  For example:  “Why did we hire this fellow?” we ask, when we discover that his unethical behavior is about to infect our entire office.  We think about it and remember that he was as well qualified for the job as the one other applicant. “He seemed so refined and so good looking!”  Another example:  “I’m sorry; I will need to think about it, I told the salesman.  I never intended to buy the computer system because I felt unsure about his honesty.  I couldn’t avoid looking at his missing tooth.


 

THE “BEAUTY RESPONSE”

Why is it that we act that way and base our decisions on “looks’? It even seems that attractiveness seems to correlate with successes both in the workplace and in the “mate-place”. 1

Why is it that the best dressed and the best looking people come off as the most talented and successful? The answer may be as simple as looking at our DNA to discover that we are actually “hardwired” with an innate attraction to beauty…2….. .

Even though that process may seem complex and puzzling we intuitively know what is beautiful and recognize it immediately. When we see a face we instantly know if it is beautiful and feel a strong, emotional connection that is usually accompanied by a high degree of attraction.  That reaction has been identified and is called the “beauty response”...…3……..Each of us responds in different ways and our responses are as varied as are our backgrounds and experiences: we might even say that beauty may truly reside “in the eye of the beholder”.

Down thru the ages man has beheld himself and noticed how plain he appeared and decided that he needed adornment and thus we see that many cultures have devoted themselves to decoration of the body as a means to beautification. While one culture finds tattoos appealing another views mutilation of appendages and teeth as beautiful, while still another relies on painting their faces and highlighted with extravagant hairstyles. In many cases those creative adornments are attempts to mimic nature.

In the animal kingdom the many varieties of body design and color have been studied and those types that are essential for the survival of each species have been studied.  For example, all insects, birds and mammals are attracted to other healthy animals especially those that exhibit robust health and symmetrical bodies those types are selected as mates….4….

As humans, we are also attracted to health and when we say someone is beautiful we usually understand the person to be talking about the face. When we first meet another human we look directly at each others’ face and interact with gestures and words:

And smile.  This is the crucial time in this initial meeting and we are either attracted of not. Our face and smile, then, become critical features to our future relationships and success with other humans. When we see a symmetrical face with a bright, gleaming smile we subconsciously assume that this person possesses robust health.

It then becomes a “judgment call”. We judge others to enjoy not only this quality of health but also to possess other abilities. We can not avoid the obvious conclusion that symmetry of the face and smile, then, are the essential characteristics for the attractiveness of the human face.

Another feature apparent for human attractiveness is averageness..5 ibid….100 years ago Charles Darwin’s eccentric cousin Charles Galton superimposed faces of many criminals attempting to see if there was an archetypical, criminal face. His composite face was simply a more attractive face than that of each individual. The results of another study and search for that “universal” face” involved people of every ethnic group: each were given twenty faces comprising every nationality and asked to choose the face that they found to be most attractive. The result? They all picked the same face!…6 ibid……We learn, then,  that cross culturally there are many common features that we find beautiful and attractive.

So it is then: We were programmed to stare unabashedly at that gorgeous face: we could not help it! For those of us who need help with enhancing the attractiveness of our smiles and faces we need to collaborate with dental and medical professionals who specialize in esthetic and cosmetic procedure.

We now realize that faces and smiles that are symmetrical and have many of the “universal features” are the most attractive. That phenomenon is a good starting place to understand our basic responses. In chapter III we will explore other elements that are essential in producing beauty, such as, proportion and balance.


 

THE LAWS OF INTERACTION and  COLLABORATION:

THE PHYSICS

When we describe the essential interpersonal, technical and logistical elements that need to be interwoven in the creation of the rejuvenated smile, especially        when our goal is  to create a masterpiece smile, we need to create a workable model for success. By taking cues from the world of physical science and by observing the properties of light diffraction and color dispersion we can construct such a model.

When we observe a beam of white light that is projected through an optical prism, we see that the beam is dispersed into all the colors of the visible spectrum. Likewise, when primary colors of red, blue and yellow are projected backwards through this prism, a beam of pure white light is recreated.


 

THE PLAYERS:  DENTIST-DENTAL CLIENT-DENTAL CERAMIST

 

By applying this physical process of light and color to our program of esthetic smile-rejuvenation, we can create a model by utilizing a modified version of the artist’s color wheel. The intersecting circles of the primary colors of red, blue and yellow are used to represent the DENTAL CLIENT, the DENTAL CERAMIST and the LABORATORY techniques and MATERIALS respectively. The ESTHETIC DENTIST plays the role of the prism that organizes filters and weaves all aspects of art and science together to create the masterpiece smile that is represented by WHITE in the center.

The secondary colors orange, violet and green represent independent interactions that the dentist must coordinate with the goals and wishes of the client: His job is to interpret and integrate this information into bright, white light: The living smile sculpture.


 

THE ESTHETIC DENTIST

This dental professional must interact masterfully in collaboration with each player in the esthetic model. His abilities to unify all the elements are the essential aspect of success. There are five essential requirements for the dentist who chooses to devote himself to the practice of esthetic dentistry.

The first two are the driving elements of the model: First, his passion for the natural esthetic and beauty; Second, a burning desire to help other people by creating natural, lifelike smiles. These two characteristics are “givens”, without which the esthetic experience and resulting smile are always mediocre. In my experience, when this powerful passion for beauty  is mixed with the knowledge that the client’s self esteem will be turbo-charged as a result of his esthetic dental efforts his relationship with all the players is infused with an “elixir of success” that  will always overcome any and all issues or difficulties that may pop up during treatment. These elements are the foundation for him and energize the molecules within the prism in which he works.

The third requirement is patience and well developed people skills especially in the area of active listening in combination with a strong ability to transfer and coordinate the gleaned information and wishes of his client to a master dental ceramist. Many times this process mimics the complex moves of a Tango where the two dancers must first learn each others’ steps before perfecting a rhythm and coordination of two moving as one as they compete for top prize. This process is essential and foundational and must be in place before attempting to go forward with any treatment plan.

The fourth requirement is an ownership of outstanding artistic skills and technical abilities. In my view, Esthetic and Functional Dentistry presents the most “extreme challenge that any health care provider faces in accomplishing successful and lasting treatments. This professional not only must master the art of the dental ESTHETIC, he must be able to provide a FUNCTIONAL design that will pass the test of tine as the art and science of Esthetic and Functional. The Esthetic Dentist must masterfully blend the visions and skills of the artistic right brain with the techniques, formulas and reason of the scientific left brain of the Functional Dentist in collaboration with the ideas and desires of the esthetic dental client.

By combining a vast background of experience and wisdom with superior technical skill with proven cosmetic, esthetic and functional dental procedures he is able to see the completed rejuvenation in his mind so that he can build it right the first time and build it to last. The tricky part is that in transforming the front teeth he must coordinate with the function of the back teeth and jaw joints and visa versa. This process we call full mouth reconstruction and must be meticulously carried out to completion.

It is a technique that is learned and perfected by hundreds of successful reconstructions completed over many years of clinical practice.

The fifth requirement is an unconditional commitment to ongoing and continuing education with new techniques and materials. Practicing dentistry on the “leading edge” requires one to move with speed and learn quickly, unless he slows down and is caught by the blade:  Then the leading edge becomes “the bleeding edge” of sloth and inertia which usually leads to mediocrity.

The fulfillment of this collaborative process is the successful creation of a beautiful smile that harmonizes with all aspects of the face to produce a living sculpture.  When I consider committing time to produce one of my sculptures I need to decide on a “theme”. Once selected I massage and nurture it until I know the essence of the content and scope of the work:  Only at his point am I able to passionately breathe life into the work.

With the Smile Sculpture, the theme is the client’s face and personality. With the proper positioning of the two front teeth followed with careful and artistic placement of all remaining teeth, the result will provide a natural underlying support for the lips as well as provide for perfect speech. The tricky part is the positioning of the back teeth so they are the proper height so that they become the underlying framework that lifts and supports the facial muscles. Teeth that are shaped and contoured with these essential elements of dental-esthetic design assist in recreating, in my mind, the ultimate art form: The human face as a living sculpture.

The re-creation of the system that I have called The Facial Esthetic Anchor (FEA) is the most vital therapy that the Esthetic-Functional-Dentist undertakes. The restoration of optimum function with respect to chewing efficiency, proper speech, and proper facial height while maintaining the health of the systems that include the jaw joints, supporting gums and bone around the teeth function synergistically to re-create this FEA: it must be restored if ideal esthetics and health is the goal. Furthermore, the FEA insures successful therapies that last by providing a framework and foundation of support for the lips, facial muscles, head posture and tilt. This becomes the frame over which many plastic surgical procedures such as lifts, fillers, implants and skin resurfacing rely on to maximize beauty and oral-facial structures of the human face.

Our face is unique and there is not another like it (unless twinned) and the elements of a smile are only a beginning to bring a smile sculpture to place. We need to consider the other players in the model


 

THE ESTHETIC DENTAL CLIENT

The reason this book and the ideas represented are written is only because of one person: the esthetic dental CLIENT! We meet for the first time as he or she comes into my office with the hope and expectation that I will be able to accomplish a “dream” smile: represented by photographs of smiles clipped out of magazines: drawings and images of smiles and faces of celebrities. There may be many pages to this dossier and they may spill out of a well worn folder on to the desktop. There may even be a spouse or a friend along to “help” with the discussion. This multitude of information along with the many opinions of friends must be focused into one idea: The creation of a natural and harmonious smile that is appropriate for the face and the personality of the client: That is my job.

By carefully listening and guiding my client toward the elements of a smile that are appropriate we make progress and come to a basic agreement as to some common features with which we can begin to paint the picture. However, we usually need to utilize other means to establish a “smile map” that can be used to generate the smile for this client.  The tricky part of this process now begins: Taking ideas and expectations about the smile and “transformatting” them into tangible, visual and three dimensional teeth that reproduce the client’s “dream” smile. There needs to be a stepwise process in place that will provide a framework to success.


 

THE FS-SYSTEM

The FS-SYSTEM of smile design is a five-step-system I have developed that insures consistent esthetic results. By managing and unifying the ideas and wishes of the client, this approach helps us arrive at our common goal which is, of course, a beautiful, natural smile and a happy client.

LEVEL I:  VIRTUAL SMILE:

We are able to produce a computerized smile “preview” to show to our client for her input. The anticipated result shown below on the right is developed with the client’s expectations and wishes in mind and by applying all elements of smile design.

The virtual-computer-generated-smile helps the client preview proposed esthetic rejuvenation therapies


 

LEVEL II:  WAX SMILE-SCULPTURE

The smile information garnered from our computer smile preview can be evaluated in 3D by creating a wax sculpture over the client’s tooth molds. The photo below shows this process. On the left is this client’s dental/ tooth situation with many unknowns. The image on the right shows the teeth with wax overlaid to create length and form.

At this point, if the client likes the way the smile looks, we can then begin to work in the mouth and directly on the teeth. Should there remain any questions we can go next to the trial smile.


 

LEVEL III: TRIAL SMILE

The wax sculpture defines the guidelines for us to fabricate plastic snap-on teeth that we call a “trial smile”. It can be worn home and used for the client to evaluate the proposed changes. Aspects such as speech, lip support, tooth length and shape as well as color may be scrutinized. The image below on the right shows upper and lower trial smiles during evaluation.

We can make any change desired and snap it back onto the teeth for further evaluation and change.

“Trial Smile” snapped in place to evaluate proposed changes. Client may wear home to further evaluate.


 

LEVEL IV:  THE TRANSITIONAL SMILE

When the client and I have co-developed an appropriate and acceptable smile design, we are ready to begin directly in the mouth and on the teeth by attaching a prototypical plastic sculpture or PROVISIONAL restoration.  We now have created “3D Projection” that becomes a TRANSITIONAL restoration of the desired result which is worn by the client for the duration of the fabrication process of the final porcelain-bonded-restoration. This is the key step in communicating with the client and the dental ceramist the size, shape, contours and the esthetic nuances necessary for the final restorations.

The middle photograph below shows such a provisional or transitional. Again, within limits, we are able to evaluate our desired result and make appropriate changes before fashioning the final restoration. When the client is satisfied with the look of this transitional we make a mold of these teeth that our ceramist will use as a prototype-model for referencing and fabrication of the final artistic restorations.

Clients often are concerned about what they will look like during esthetic dental treatment. The center photo illustrates the interim, transitions smile.


 

LEVEL V:  ARTISTIC COMPLETION

The photos below show before and after images of an FCS- Smile Sculpture. By going thru this FS-System of smile development we not only were able to create natural and lifelike teeth that rejuvenated this client’s face and smile but the overall esthetic also enhanced her self esteem and confidence.


 

THE ESTHETIC DENTAL CERAMIST

Unless the Dentist is also a Master Dental Technician he needs to develop a successful working relationship with the most talented, and available, Dental Ceramist in the field. The technical and creative abilities of the Ceramist are a vital link to a stunning smile makeover.

This Ceramist must possess many of the left and right brain skills of the esthetic dentist. The combination of artistic skills and technical background with his talents of interpersonal and listening skills is essential in order to assimilate and communicate data and the ideas of the Dentist and Client. The goal is to translate verbal, visual and conceptual information into a final result that makes sense and will produce a smile that makes the Client happy

The Ceramist will usually meet and interact with the Client before the Level II appointment or just after the Level III appointment.   Utilizing digital photographs and color maps of the teeth he sharpens his listening skills and attempts to visualize and translate the thoughts and desires of the Esthetic Dentist and Dental Client into a working prescription that combines color and shape with the personality of the Client.

The next essential Ceramist-Dentist collaboration involves most of the “behind-the scenes” planning and fabricating activities of the porcelain-bonded smile Sculpture:  Activities that are now driven by the many ELEMENTS OF THE SMILE that must be evaluated and applied to the rejuvenated teeth of the Client. These are the topics of discussion in the next section.


 

LAWS OF THE ESTHETIC

THE NATURAL ESTHETIC

The inherent beauty in nature is undeniable.  We view a flower and our senses tell us immediately whether it is worth admiration or not. Factors such as shape, color, proportion and symmetry are evaluated in a way that we immediately see the natural truth that all beautiful objects contain rounded arcs

that connect and interrelate to each other in a symmetrical and harmonious mathematical formula called the Golden Proportion.

If the color is stunning and the proportion is wrong we see deformation not beauty.

We would choose the Camellia on the right to display on our windowsill


 

THE DENTAL ESTHETIC

The same esthetic principle applies to teeth, faces and smiles. Teeth that are flattened and crooked like the woman’s teeth below on the left remain hidden behind the lips until she smiles. The natural esthetic of her sensuous lips is completely forgotten after she smiles as we, then, completely forget about the luscious lips.  The teeth on the right, however, harmonize with the lips to create and enhance the “smile esthetic”.

Left:   Crooked and deformed  teeth  draw our attention away from the beautiful and luscious lips. Right: Beautifully shaped teeth support beautiful lips.

A natural and youthful smile is a result of radiant color when combined with a pleasing harmony of tooth size. Also, note how the healthy gum tissues frame each tooth.

Teeth possess optical characteristics that must interact with each other to produce a natural esthetic. The crystalline structure of outer enamel and interconnecting layers of dentine combine with water in a way to produce effects such  as, opalescence and fluorescence. Other characteristics such as surface reflection, light refraction and translucence are dependent on the surface texture and thickness of the tooth’s enamel edge. The images below demonstrate many of these properties as seen when light with various wavelengths illuminate the tooth.

From Left to Right: translucence: fluorescence:  diffraction: opalescence.

From Left to Right: refracted light: reflected light: translucence: opalescence.

Young teeth and unworn teeth present an enamel edge that looks youthful and vibrant because every optical factor is present in the enamel edge of the tooth to contribute to this natural esthetic. Whereas teeth that are flattened because of uneven wear lose their natural vitality and darken due to the attrition of these essential factors over time. In other words, worn teeth look old and unworn teeth look young. Our goal as Esthetic Dentists is to utilize nature as our model when rejuvenating an old, worn smile.

Left: YOUNG and unworn tooth displaying a translucent edge as a result of two layers of enamel and no dentin layer underneath. This is a youthful look!

Right: OLD and worn tooth that displays only the yellow and harder underlying dentin color. This is an aged look!

The back teeth also are beautiful and esthetic when viewed in the smile. They possess biting surfaces with two to five cusps and transition away from the edges of the front teeth with the pointed cuspid or “eye tooth” to provide support for the lips and cheeks. Their broad outside surfaces along with their gentle sloping cusps are responsible for finishing the smile, “showing off” the potentially dark recess between the teeth and the cheeks known as the buccal corridor

A harmonious, broad smile: The result of an esthetic transition from the even edges of the front teeth to the broad pointed back teeth. Again note how the gums frame each tooth.

The chewing surfaces of the back teeth are designed to pulverize foods as an integral part in the first step of digestion.  These surfaces also are beautiful in their own right as they display grooves and ridges that gently arc in and out of mastication fossae: these features are strikingly similar to the ascending and descending surfaces of mountains.

Left : Rugged features of a young alluvial system Middle: Lower five- cusped molar; Right: Mature mountainside displaying “cusp and fossa” configuration.

I have a theory about the similarities between molar teeth and mountain sides. I think that mountainsides erode over time into an optimum shape that allows for maximum watershed: thereby slowing down and perhaps curtailing any further erosion. Therefore, their function is for rapid sluicing of a natural material: that being water.

Molar and bicuspid teeth also are designed for masticating foods.  They too display gentle grooves or sluiceways with sharp ridges on either side that are designed to cut and grind. Food is directed downward by the sluiceways into the fossa of the tooth where it is ultimately pulverized against a matching “bite mate”.

Teeth are “fully armed”, so to speak, to provide optimum function.

When they posses this type of anatomy of the biting surfaces. When foods are easily masticated the teeth, the bone around the teeth and the ligaments and bones of the jaw joints will develop few problems over time, if any.

In my view, both systems exhibit surface configurations that are designed with the mindset that states that” form follows function”. Therefore, the resultant anatomy of the tooth is similar to the topography of the mountainside because of the requirement of an efficient and dependable system that will experience, over time, a minimum of wear and tear.  More information next chapter about what happens when the back teeth wear out with a flattening out of these grooves and ridges.


 

LAWS OF DENTAL FUNCTION

TEETH IN FUNCTION

The location of your teeth and their function as an integral part of your digestive system highlights their importance to you. To quote Russell C. Wheeler, D.D.S., from his textbook, Dental Anatomy and Physiology,  “Teeth must be regarded as instruments…..instruments to be used for the cutting and comminution of food during the process of mastication… ……normal tooth form plus proper alignment, assures efficiency in mastication of food” ..6..

Your teeth are designed and engineered to last your lifetime.  In fact, they are the hardest and strongest structures in your body. The outer layer called ENAMEL is shown on the tooth to the right.  It is composed  of  90% Hydrox-yapettite (HA) combined with protein and 10% water. The inner layer and soft part of your tooth is called DENTIN and is composed of 67%  HA, 3% collagen and 10% water.

Binding enamel with dentin produces a superbly resilient and somewhat elastic structure that can flex during your powerful chewing and grinding cycles: Combined with its inherent toughness, your teeth can withstand most natural forces.  However, degrading forces, such as tooth grinding and attack by acids cause untold damage to the health of your teeth especially if your teeth are crooked. The milling effects of grinding cause you to wear away the tops of your teeth and expose the soft underlying dentin and to create through and through cracks of the tooth structure. Crooked teeth catch and trap food particles that provide a convenient source for germs to feed.  Both of these situations accelerate the breakdown and destruction of your tooth.

For those of you who have crooked teeth, you do because our jaws are just too small for the size of our teeth. Our teeth are genetically programmed to grow to a predetermined size and shape. However, our contemporary lifestyle has produced eating and breathing habits that directly cause this problem. Our preference to consume soft, processed foods rather than natural, fibrous foods that require more vigorous and prolonged chewing, along with our inability to breathe through our nose has “stunted “ the growth of our jaw bones so that our teeth were prevented from interconnecting or functionally occluding. When this happened during the growth and development of our jawbones the normal biting forces are dissipated. “These growth forces that cause the teeth to align themselves in an ever-widening arc are not influenced by the jawbone, but influence the jawbone to grow and accommodate the teeth”…7..

In other words, our teeth finally erupted into our mouths to find a smaller jawbone to fit into, and by necessity, crowded together without connecting with their “bite-mates”. The forces needed to stimulate our jaws to grow is supplied by straight, fully occluding teeth: Therefore, our jaws remained withered and our teeth remained mal-occluded.

Our jaw muscles are irritated by the uneven teeth and react by trying to grind away the crooked interferences so that the teeth will fit together.  The resultant milling process flattens the tops of our back teeth and the edges of our front teeth. Also, our teeth may loosen and “wiggle about” in the jawbone. When this happens, some of the bone around the roots of our teeth dies and dissolves.  Eventually the gum pulls away from the tooth and the gums recede.

The aging effects caused by the wear and tear of tooth grinding, also referred to as bruxism, show themselves most proximately in the smile and face. All of our teeth grow into our mouths with beautifully shaped contours: Our front teeth have fully rounded and thin edges that display lifelike, translucent and lustrous surfaces; your back teeth have fully developed cusps that harmonize with the youthful appearance of our front teeth.

These youthful elements are all but ground away through bruxism and the teeth lose their edges and become flat and lifeless. Furthermore, as your teeth are flattened the face changes too: the consequences to the face include a closing of the jaws so that the jaws are closer together so that your lips purse together with a myriad of extra wrinkles that form around the nose, lips and chin. Also, the corners of your mouth droop downward and the height of your face is shortened.

The mouth above shows the effects of an aged smile and face: On the right is the same mouth fully rejuvenated with Esthetic and Functional porcelain restorations.


 

THE DESIGN OF TEETH

The phrase “form follows function” is one mandate utilized in the engineering and design of tools that are designed for specific jobs:  The same principle applies to your teeth.

The front teeth or INCISORS have thin cutting edges similar to chisels: their job is to hold and incise or cut our foods. The eye or canine teeth are called CUSPIDS: They are the pointed and bulky “fang-like” teeth that are shaped liked dull hooks and are designed to grab and hold food. The back teeth have multiple cusps: Two for the BICUSPIDS for holding and initial grinding; Four to five for each MOLAR.  These back teeth have biting surfaces shaped like milling cups and pestles articulated into a system that is designed to easily grind and pulverize your food. Your teeth work together much like a team, with individualized designs that mimic cutting and grinding tools: this functional design is essential for the initial process in digestion.

It is well understood that your health, well being, and longevity are directly related to your ability to effectively masticate food as a first step in the process of assimilating those nutrients gleaned from various foodstuffs: Hence, properly pulverized and mixed with the salivary digestive enzymes, our meal is ready for further digestion in the gut.  Incomplete mastication of food taxes the digestive abilities of the stomach and so diminishes the content and quality of vital minerals and nutrients. Nutrients that remain bound and undigested pass thru the gut and eventually out into your outside plumbing.

When your teeth are worn flat it is necessary to choose foods that do not require much chewing or mastication. Our modern civilization has provided us with marvelous and unimagined conveniences, and relevant to your teeth is the availability of soft, processed and refined foods along with endless supply of refined carbohydrates in the form of white flour and sugar. Both of these foodstuffs are largely responsible for the diseases of the mouth that cause us to lose, break and fracture teeth.

Those “pure” sugars are the “main course” entree as chosen by the germs and bacteria in your mouth.  They are able to immediately feed and metabolize those refined sugars and produce caustic acids and enzymes as a byproduct. The acid causes the crystals of HA in the enamel and dentin of your tooth to dissolve and leave a micro-hole into which the germs can invade the tooth, just like an infection.

The enzymes dissolve the skin that covers your gums and allows the germs to invade your gums:  Hence, tooth decay and periodontal, bone disease is actual bacterial infections: Infections that can destroy your teeth and ultimately result in tooth loss


 

THE DESIGN OF OCCLUSION (BITE) AND JAW JOINTS

NOTE:  Read on only is you want to develop a sophisticated understanding of the relationship of your front teeth and overall dental health and longevity. It may take a focused concentration! If you read it, it will be worth it!

The purpose of this section is to provide you an overview into the second most important aspect of all Esthetic Rejuvenations: that being Longevity: in other words, how long the restoration will last. It all depends on the effective management and link-up of the esthetic needs of the front teeth and smile with the functional requirements that matches front teeth to back teeth to jaw joints.

Occlusion is defined by Webster as “the fitting together of the teeth of the lower jaw with the corresponding teeth of the upper jaw when the jaws are closed” The teeth must match each other evenly and allow simultaneous articulation of the two jaw joints. The degree of health and stabilization of your teeth and supporting bone is a direct result of the level of health of a system called the Gnatho-Stomatic system (GMS).

`This GMS consists of your right and left jaw joints (called the Tempro-Mandibular-Joints or TMJ), the chewing or occluding surfaces of your teeth and the supporting bone and gums around all of your teeth.  In respect to the individual teeth, they “should be examined for their own pathologic conditions but in addition should be viewed in their relationship to, and in contact with the opposing tooth. By way of the neuromuscular mechanism its supporting structures may influence the masticatory system as a whole”…8..  In other words, the basis for long term health of this system is all about the Yin-Yang principle of form and function. If your teeth are formed perfectly and your jaws have been allowed to grow to their maximum and proper size, your teeth most likely are straight and positioned within the jaws so that the biting surfaces properly inter-digitate: and I would say that you display normal, functioning occlusion and that you have a good chance to have healthy teeth, TMJ and supporting bone with a very low risk of developing dental problems throughout your lifetime.

According to NATHAN ALLEN SHORE, DDS, “Principles of occlusion and articulation form the basis for every aspect of dentistry. Occlusion and Articulation are based upon the principle of function and the purpose of all dentistry is the maintenance of the restoration of function.”..9.. Furthermore, “the Functional rehabilitation of the masticatory system is essentially comprehensive, embracing interception prevention of deterioration including periodontal disease.

The articulations of the teeth simultaneous with bilateral contact of both the right and the left TMJ is essential when evaluating and treating either the front teeth or the back teeth.” ..10..

It is essential, as a goal of treatment, to attain a simultaneous positioning of both joints with the complete occlusion of the teeth thus providing a Tripod system:  that system is the most stable and functional.  Our created restorations will be both beautiful as well as functional: in other words we must create Esthetic dental restorations that are also Functional!

When a functional occlusion is established with respect to the back teeth and jaw joints, the muscles that move the jaws will remain relaxed and “de-stressed”. In other words, there is little tendency to grind and rub the teeth together except when chewing food; thus reducing the effects of wear and tear exhibited when teeth are out of balance. Not only do the back teeth continue to wear out again but the front teeth are placed at risk.  The rubbing of the front teeth  or “Bruxing” causes undue stress on the new porcelain restorations which causes them to chip, fracture, pop off and wear unevenly.

The bottom-line:  Functional Esthetic Rejuvenations are built to LAST! Non-functional Esthetic Rejuvenations are built to FAIL!

The next section deals with the criteria involved with the development of an overall dental esthetic that results in the achievement of each Client’s individual SMILE DESIGN.


 

LAWS OF EVALUATION

THE PORTRAIT: THE LIVING SCULPTURE

The Esthetic Dentist has the obligation to Rejuvenate his client’s smile in a way that naturally pulls together all aspects of the face so that each element complements the other.

The esthetic dental adventure that both he and the client participate in must culminate with an artistic masterpiece…

…called the living Smile Sculpture…

When an artist contemplates the creation of a sculpture he first must select a THEME or message he wants to share with his audience. Only after sufficient time is spent massaging and living with the theme will he be able to shape a vision and it is essential that he “sees” the artistic result in his mind’s eye before he can begin, As he starts this artistic journey, one that is both a physical undertaking and an emotional experience, he knows by experience that his commitment to complete this sculpture must be unconditional because many times problems and adversities crop up to deflect his enthusiasm.

Once the artist is inspired and breathes life into this work with his artistic passion, there usually is no turning back. At these times he is sustained by a vision that is welded by the passion and love he feels for his work: Such is the case with the sculpture below.

Those processes experienced with the creation of fine art are virtually identical to those of smile rejuvenation. The THEME for the Esthetic Dentist is simple:  His client and his or her face. His client’s characteristics and personal attributes, such as, personality, life style, occupation and culture affect artistic decisions that must be made about the front teeth as much as do the structural features of the face.

All faces are different (even with twins!) in respect to features such as size, shape, contours, profiles, complexion and skin textures, eye size and color, cheek and chin size, and hair color and texture.  Those personal characteristics must be systematically evaluated and applied to aspects of the teeth, they affect decisions the dentist uses in the creation of a natural, lifelike and appropriate smile for his client.

The teeth within the smile are responsible for the dynamics of clear and fine enunciation and speech as well as producing and assisting with the many captivating facial expressions that are the most beautiful and alluring.  The opposite is true when a smile is composed of teeth that are misshapen, mal-positioned and discolored.  This smile is always tentative.  The speech may be unclear and the facial expressions are reserved, even tending to be painful. A good example of this factor is witnessed in the before and after photo of a Smile Rejuvenation as viewed below.

The transformation of a “grimace” into a pleasing, vibrant smile

Before we go any further with the discussion of the smile we must examine those structural characteristics of the face that determine the look and function of the front teeth. Especially, we must closely examine the most dominant feature of every natural and beautiful smile: The two front teeth or central incisors.


 

SMILE DESIGN

The following section is intended to present the Elements of a Smile in a practical and usable format.  I have applied the details with one patient so you may witness the growing development of an actual Smile Rejuvenation.  Also, many of the elements will apply to your situation and you may wish to use this information as a guide in the development and evaluation of your own smile.


 

OUR THEME: THE FACE

The artistic elements of a smile need to be identified for each prospective cosmetic/esthetic dental client.  Since we are all different, these features must be evaluated and interwoven in such a way that they support one another with harmony. These details, however, must be viewed from a larger perspective: they must blend and balance with the THEME, which is the face.


 

ELEMENTS OF A SMILE

The following 10 factors are the major smile elements that must be artistically blended in order to create a spectacular and stunning smile:


 

THE SIZE AND SHAPE OF THE FACE

Each face is the unique expression of genetics, personality, age and health with modifications derived through the utilization of many of the following methods:

The application of cosmetics to the skin

Framing of the face with varied hairstyles and color;

Adornments such as jewelry to enhance the overall appearance as well as to distract attention away from asymmetries, wrinkles and folds in the skin

Plastic surgery therapies to temporally help reverse the look of the aged face;

Lotions and tonics to firm and smooth the skin

Exercises to tone the facial muscles

When these cosmetic approaches are utilized individually or as a whole, they fail in their overall esthetic effect when the teeth of the smile are ignored! It would be like a beautiful landscape painting that is painted around a jagged hole in the center on the canvas.  The appropriate method of facial rejuvenation MUST include the Smile in the overall planning.

Planning to rejuvenate the smile of his Client, the Esthetic Dentist utilizes structured methods of evaluation, such as, standard facial landmarks and mathematical formulas. Other aspects   of designing a smile include expressions that are intuitive and artistic that include the client’s personality type, the client’s perception of herself and how she wants to be perceived in public and decisions about “a look” that is appropriate for the age of the client.

The face is our starting place in determining where the two front teeth must be located. The red landmarks on the RIGHT are used to position the center and angle of the of the smile.


 

LANDMARKS OF THE FACE

The oval diagram below highlights the facial landmarks from the previous page so that we can isolate the eyes, smile and upper teeth and visualize them more clearly. They are arranged as follows:

ab:     The Midline of the Face- drawn through the tip of the nose and a point halfway between the pupils.

cd:     Inter- Pupillary Line- drawn through the center of the pupils. Ideally should be perpendicular to midline.

ef:     Comissural-Line – line connecting the corners of the mouth when smiling. Ideally should be perpendicular to the midline.

gh:     Incisal Line:  line connecting the incisal edges of the two front teeth..

The landmarks ab and ef are the  essential starting  place to locate and  position  the two front teeth.  A sight deviation from the midline is acceptable: however: gh must parallel ef.

Each face is unique: And it follows that each smile should also be unique because it must harmonize and integrate with the elements of the face with respect to the size and shape, the complexion, and the coloration and surface texture of the skin.

Shape and size are considered first: Faces are shaped in the forms of either ROUND or SQUARE or OVAL or HEART; the most important feature however, is SIZE.

The ideal ratio for the width of the face to its length must also be the ratio of the width to length of the central incisors: This ratio is called the GOLDEN PROPORTON or GOLDEN RATIO.

AB:  width of  the face. CD:  length of the face. CD/AB = 1.62 = GOLDEN RATIO

So: First, determine the SHAPE; Second, determine the SIZE.

Now, we are ready to fit the teeth into the smile.


 

SIZE AND SHAPE OF THE CENTRAL INCISORS

The smile is the most dominate feature of the face second only to the eyes. The dynamics of expression and speech highlight the importance of the teeth within the boundary of the lips.

If you will, the smile is much like a Broadway play where the lips are analogous to the curtain, the teeth are the actors and the gums are the scenery. Now, when the Curtain (Lips) goes up there can only be TWO STARS (Teeth) and all others (Actors//Teeth) must be Featured Extras. So, let’s start by locating and sizing the stars.

CENTRAL INCISORS

Size: ab/cd = Golden Ratio = match to the face.

Location: Midline of the face.

Incisal edges perpendicular to the midline of the face.

The central incisors (“The two Stars”) must dominate the smile.

When they shine the smile shines!

When they are poorly made the smile is weak and dull!


 

TOOTH SIZE AND THE GOLDEN PROPORTION

The visual width of every tooth in the Smile-Zone must harmonize with its neighbors by the formula of  1: .62, OR by the Golden Proportion.

In this example the width of the central incisor A is 1.62 wider than B which is 1.62 wider than C and so on moving backward  into the smile


 

ARRANGEMENT OF TEETH

The teeth must be arranged so that the edges of the front teeth and the cusps of the back teeth parallel the arc of the  smiling lower lip.


 

GUMLINE SYMMETRY WITH UPPER LIP

The gums should not have an excessive or “ gummy look” as this example does. Ideally the heights of the gums of the central incisor and the cuspid should be the same. The middle or lateral incisor should be slightly shorter, and the height of the gum for the next tooth, or the bicuspid, should be close to the visual height of the lateral incisor.


 

A BROAD AND WIDE SMILE

The teeth should fill the The Buccal Corridor (the space between their outer surfaces of the teeth and the inner surface of the cheeks) when smiling.  If not, there appears an unsightly dark space and in many cases it looks as if there are missing teeth behind the cuspids or “eye teeth”.


 

TOOTH PLACEMENT

The teeth must be positioned so that “the look” of both sides of the smile must be within the harmonies of the Golden Proportion.

The ideal smile should show a mirror image left-side to right-side.

AXIAL ANGULATIONS OF THE TEETH

There should be a slight tilting of the visual surfaces of the teeth away from the vertical midline as they approach the corners of the mouth as illustrated with RED lines.

When teeth tilt or tip inward too much (YELLOW lines), the smiles looks weak, the teeth appear too short and often there is excessive buccal corridors with darkness behind the cuspids.

TOOTH-TO-TOOTH CONTACTS AND HEIGHT OF PAPILLA

It is important that each tooth abuts against its neighbor in a very specific location in order for the smile design to be complete:

Likewise, the location and the position of the tip of the gum tissue called the PAPILLA, must be precise. The example above illustrates both of these elements.

In BLUE, the tooth contacts widen as they progress toward the corner of the smile as well as staying symmetrical to the curve of the lower lip. In Yellow, the tip of the papilla, in RED, also must reflect the curve of the lower lip.

ZENITH POSITIONS

Just like a fine art painting that is either enhanced or degraded by its frame, each tooth must be framed properly by the margin of the gum tissue in order to display pleasing esthetic harmony and beauty.

Along with proper angulations, the ideal ZENITH for each tooth or the highest point of the gum as it arcs around the top of the tooth needs to be positioned at approximately 2/3 the distance along that arc. The illustrations above show this element in RED along with properly placed angulations.


 

TOOTH SILHOUETTES

When viewing a cityscape through a mild fog one can see only the shapes of the buildings: and it is these shapes that tell the architectural story of proportion and design. We immediately know if the shapes are “right” and true. The same can be said about the design of a beautiful and harmonious smile.

The properly designed smile displays the unity and harmony of tooth contours that radiate toward the corner of the mouth as repeated silhouettes. This is a smile that we immediately know as “right”!

The silhouette created by this dark background highlights the EMBRASSURE forms of the front teeth. Designs must be different for each individual as these silhouettes must create an appropriate match with the personality, age and lifestyle of the client. Esthetic smile design is a success only when these elements are utilized and result in lifelike and natural teeth.


 

THE EMBRASSURE FORMS

The artist utilizes the powerful element of negative space or rather darkness and shadow to highlight and support essential visual elements of the painting.

The darkness of the mouth behind the teeth is just that negative space that is the background of the edges of the front teeth.


 

COLOR AND INTERNAL CHARACTERIZATIONS

THE BEAUTIFUL SMILE VS. THE STUNNING SMILE

The essential “product” in our efforts as Esthetic Dentists is the restoration of our client’s self esteem and confidence. By following the steps and principles of Smile Design in the forgoing discussions it is possible for the dentist to create a beautiful result. However, to create a truly STUNNING SMILE and masterpiece of body and soul one must spend considerable time with the client and delve deeper on an emotional level.

When I started to think about my client’s smile and develop a vision that embodies her expectations we were faced with numerous unknowns. By utilizing the format of analysis we could isolate and objectively looked at each element. By carefully managing and interweaving all of the smile elements, we are able to foster predictability as to the outcome of her final smile rejuvenation.

We must, however, breathe an element of life and vitality into the smile creation in order to bring aliveness to the “product” that appropriately reflects the client’s personality, lifestyle and in many cases, the client’s relationship expectations of anticipated success in business and romance.

Of course, standing back to look at the complete package is the ultimate test in evaluating our efforts: We look and ask these questions…

Did we match up the overall esthetic to our patient’s personality?

- Her social temperament?

- Her coloring and complexion?

- Her skin tone and texture?

- Her facial characteristics and proportion?

Did we help boost her self esteem?

Does she feel rejuvenated and is she happy with the transformation?

Every answer must be YES!

When the answers to those questions are all “Yes,” then we have truly created a Masterpiece Smile Sculpture.


 

LAWS OF ACTION

PERSONAL SMILE EVALUATION

This section illustrates most of the problems that we as Esthetic dentists are asked to solve.

I have displayed them side by side with their cosmetic/esthetic dental solution.

You can evaluate your smile by following these steps:

Turn back to the section, ELEMENTS OF THE SMILE.

Locate a problem similar to yours by referencing the guide on the next page. 

Note that all of these examples show the beginning situation on the LEFT and the after smile on the RIGHT.

Use a mirror or take a digital photograph of your FACE and SMILE, attempting to match the style and size of the examples, and project it onto a computer monitor. 

Print a copy of each image onto which you can draw your own smile analysis and arrive at a basic solution.

Have fun and good luck!


 

COSMETIC DENTAL PROBLEMS AND SOLUTIONS


 

CATEGORIES OF COSMETIC//ESTHETIC DENTAL THERAPIES

The object of cosmetic//esthetic dental treatments is BEAUTY and the process and the techniques utilized depend on many factors.

The three questions that you, the client, must answer are:

What do you want your smile to look like?

How long do you want it to last?

How much will it cost?

When your expectations and means are low-to-medium, it is best to follow a COSMETIC approach where your smile may be ENHANCED by utilizing a combination of minor orthodontics and slight alteration to your natural tooth surface by re-contouring, whitening and cosmetic bonding.

On the other hand, when your expectations are medium-to-high and your clinical situation is challenging you must be evaluated for ESTHETIC therapies that include MAKEOVER AND REJUVENATION: these treatments usually require the strength and beauty of Porcelain-Bonded-Restorations: referred to as PBR.


 

COSMETIC DENTAL THERAPIES

(MINOR COMPLEXITY)

Cosmetic dental procedures are used to cover up stained and discolored teeth and to slightly correct crooked teeth. Therapies available include:

Minor Orthodontics

Smile Whitening

Cosmetic Re-Contouring

Cosmetic Bonding

Gum Lifts

Direct Composite Veneers

Indirect Porcelain Veneers


 

SMILE ENHANCEMENT: DISCOLORED TEETH

Cosmetic Re-Contouring

Cosmetic Bonding


 

SMILE ENHANCEMENT: SHORT TEETH

In-Office Smile Whitening

Porcelain Veneers


 

SMILE ENHANCEMENT: FLARED TEETH

In-Office Smile Whitening

Cosmetic Re-Contouring

Porcelain Veneers

Cosmetic Bonding


 

INSTANT ORTHODONTICS: CROOKED TEETH

Gum Lift

Internal Bleaching

Porcelain Veneers

All-Ceramic Crowns


 

ESTHETIC DENTAL THERAPIES

(ADVANCED COMPLEXITY)

Esthetic dental procedures are used to make major changes in teeth coloration, condition and function. In addition, associated problems like TMJ are addressed.Therapies available include:

Cosmetic Dental Therapies (see above)

Orthodontics (Instant and Traditional)

TMJ Therapy

Occlusion Equilibration

Porcelain Bonded Veneers

Porcelain Bonded Onlays

Porcelain Bonded Inlays

Porcelain Bonded Crowns

Smile Restoration---Complex

Smile Makeover

Smile Rejuvenation

Full-Mouth Reconstruction


 

INSTANT ORTHODONTIC SMILE ENHANCEMENT

Take-Home Smile Whitening

Porcelain Veneers


 

SMILE RESTORATION: BROKEN TEETH

 

Home teeth whitening

All-ceramic crowns


 

SMILE RESTORATION: MISSING TEETH (CONGENITAL)

(2) 3-Teeth Ceramic Bonded Bridges

Smile Whitening

Gum Lift


 

SMILE RESTORATION: MISSING TEETH

 

(3) Implant-Supported Porcelain Crowns

(3) Dental Implants


SMILE MAKEOVER: COLOR AND SHAPE

(10) Porcelain Veneers


 

SMILE MAKEOVER: LOP-SIDED SMILE

(16) All-ceramic Porcelain-Bonded Crowns


 

SMILE MAKEOVER: GRIMACING SMILE

(8) All-Ceramic Porcelain-Bonded Crowns

(6) Porcelain Veneers

Take-Home Smile Whitening


 

SMILE REJUVENATION: CALICO TEETH, WORN AND FLATTENED TEETH ON LOWERS

(8) Porcelain Veneers

(2) All Ceramic Crowns

Cosmetic Recontouring

Gum Lift


 

SMILE REJUVENATION: STAINED TEETH, CROOKED TEETH

(14) Upper Porcelain Veneer Restorations

(6) Lower Porcelain Veneer Restorations

Take-Home Teeth Whitening


 

SMILE REJUVENATION: SHORT TEETH, FAILING CROWN POSTS, GUMMY SMILE

(4) Ceramic Post Reinforcements

(14) All Ceramic Bonded Crowns

Internal Whitening

Gum Lifts


 

SMILE REJUVENATION: FLARED BUCK TEETH, STAINED TEETH, CROOKED TEETH, SHORT TEETH

Cosmetic Re-Contouring

(8) Porcelain-Bonded Veneers

(4) All-Ceramic Bonded Crowns

Advanced Gum Lifts


 

PLASTIC SURGERY AND COSMETIC SURGICAL ENHANCEMNENTS

Often our dental client has unrealistic expectations about the overall appearance of outcome of his or her face and smile. In an attempt to accomplish our client’s vision, we must incorporate the many refinements available via Cosmetic//Esthetic Plastic Surgery, Orthodontics and Oral Surgery given the existing facial asymmetries, results of aging, residual trauma defects and growth deformities in the face

Our starting point is to interface our ideal and estimated smile design with the Facial Mask Analysis. By evaluating the result we are able to readily identify those areas of the face that will need to be changed to be in harmony with the projected smile.

ESTHETIC//PLASTIC PROCEDURES

Face and Brow Lifts

Eyelid: Blepharoplasty

Nose: Rhinoplasty

Ears: Pinnaplasty

Chin augmentation: Genioplasty and Implants

Cheek implants

Cheek augmentation/ wyatt

Vein removal

Dermal Fillers

Liposuction

Botox

ORTHODONTIC-GNATHIC SURGERY

Many times one jaw is larger than its mate or there are unmanageable asymmetries with both the jaws and the teeth that need to be corrected by combining dental therapies of Orthodontics and Oral Surgery before Esthetic Dental and Surgical procedures are started.

THE GOAL:        Provide a symmetrical and supportive framework of the hard tissue of the face, in this case the teeth and jawbones, where the muscles of the face and facial expression receive maximum and hopefully ideal support so that the Plastic Surgeon will be able to utilize minimum procedures that are in reality just “touch ups” so that the resultant facial esthetic will be beautiful and long lasting.

Once the teeth have been orthodontically moved into an ideal position, the jaws are then surgically positioned into the ideal, preplanned locations so that when healed will present our ideal and esthetic created beforehand.

THE TREATMENT:

Possibilities include:

Upper/Lower jaw augmentation or reduction

Instant orthodontics

Chin and cheek augmentation

Liposuction

THE TEAM: The Esthetic Dentist, if you will, acts as Quarterback by coordinating the efforts of his team of specialists: Orthodontist, Oral Surgeon and Plastic Surgeon.

Above:  Orthodontic treatment completed and before Ortho-gnathic surgery

Below: After surgery that included moving the lower jaw back, the cheekbones foreward and recontouring the chin.

LAWS OF SELECTION

CHOOSING AN ESTHETIC//COSMETIC DENTIST

You must know the answers to the following ten questions when choosing a cosmetic/esthetic dentist:

What is the cosmetic dentist’s training and educational background?

How many years has he/she been specializing in this area?

Has the dentist had experience in the procedure you are considering?

Does the dentist work with a Master Ceramist instead of a “Production” dental lab technician to create your new smile restorations?

What additional continuing education certifications and professional memberships does the dentist have in the field of cosmetic dentistry?

Are Before and After Photos available for your type of procedure(s)?

Patient Testimonials: May you contact a patient who has had your type of procedure performed?

Does the dentist use modern diagnostic and treatment technology? For example, lasers, diagnostic      camera and computer imaging software, magnification, fiber optics, micro-abrasion and adhesive bonding?

Does the dentist have a philosophy of care that will assure  predictable long-lasting dental health

Will you receive a comprehensive dental examination and be offered sound treatment options

Is your prescribed treatment comprehensive, prioritized into phases and, if possible, planned over a period of time.

Many times it is practical to interview as many as three dentists before you decide, especially if you have a complicated situation.

Other factors will come “into play”, for example: how you feel about your experience while in the office; the manner in which you are treated on the telephone and greeted in the office; location and appearance of the office; appearance of the dentist and staff; overall cleanliness of the office; quality of before and after photographs; your perception of the dentist’s artistic skills and technical abilities.

COSTS AND TIMING

Many times the factors of cost and timing affect the final decision about which esthetic, dental treatment is appropriate for the client. It may be helpful to describe, cost out and list benefits/risks of some of the simple procedures and restorations utilized with Cosmetic Smile Enhancement. The following  procedures are the backbone of cosmetic dentistry:

HOME WHITENING

TREATMENT TIME:

Usually 3-5, 2-hour sessions. It is suggested that three or more professional cleanings per year be given after treatments are completed to help keep the teeth stain free.

PATIENT MAINTENANCE:

Thorough brushing after meals is necessary to avoiding plaque accumulation.  Smoking and such stain causing foods as coffee, tea and red wine should be avoided.

RESULTS OF TREATMENT:

Deep yellow and brown stains can be consistently lightened.  Grey/brown banding of teeth, such as with tetracycline staining is the only problematic situation.

RANGE OF LIFE EXPECTANCY:

Indefinite.  Annual touch ups may be required

COST:

Approximately $250.00 to $400.00 per arch

ADVANTAGES:

Safe procedure

Painless

No tooth reduction

No anesthetic

Least expensive of all treatment options

DISADVANTAGES:

None

COMPOSITE RESIN BONDING

TREATMENT TIME:

Usually one or two office visits.  The first visit will take about one hour per tooth.  If a second visit is required, it will usually take no more than one hour for all touch ups and final polishing.

PATIENT MAINTENANCE:

In order to keep the bonded restorations looking their best, you should have professional cleaning 3-4 times a year to remove microscopic stains and plaque that can discolor the surfaces.  The bonded surfaces are not as strong as your enamel so protecting them by avoiding biting tough foods and grinding of your teeth are essential to extend longevity! Foods to avoid biting with your front teeth include ribs and other boned foods, hard bread crusts and jerked meats. Expect to have some re-polishing and repair periodically.

RESULTS OF TREATMENT:

On the spot correction of crooked and spaced teeth. Masking dark and stained teeth is less effective.

AVERAGE RANGE OF TREATMENT LIFE:

2-7 years depending upon bite and lifestyle factors.  May need repair and replacement more frequently.

COST:

Approximately $ 200 to $1000 per tooth depending on situation.

ADVANTAGES:

Painless

Immediate (one-appointment) results

Potentially reversible because of little or no tooth reduction required

Generally less expensive than crowing and “capping” procedures

Avoids potential pulp ( tooth nerve) or gum irritation

DISADVANTAGES:

Can chip and stain

Extreme care must be taken to avoid metals such as hair pins from coming into contact with bonding

Bonding has limited life expectancy

Certain types of stains and tooth colors can not be masked with bonding

May involve minor tooth reduction to remove stain  and correct crooked teeth

PORCELAIN VENEERS - LAMINATED VENEERS

TREATMENT TIME:

A minimum of two office visits: The first visit to shape fabricate provisional restorations and take impressions; The second visit to fit and cement the final restorations. Complex esthetic cases require more visits.

PATIENT MAINTENANCE:

The teeth need to be professionally cleaned 3-4 times year.  Some precautions on eating habits are similar to bonding; take care when chewing into hard foods or incising with your laminated teeth because they will not be as strong as enamel.

The sonic toothbrush (SONICARE) is recommended for all porcelain surfaces because it efficiently removes stains.

RESULTS OF TREATMENT:

Veneers create the most natural appearing and lifelike result of all esthetic/cosmetic dental treatments.

AVERAGE RANGE OF TREATMENT LIFE:

Average life expectancy 10 to 15 years. Many cases exceed this average especially with development of stronger porcelains and when occlusion is managed properly

COST:

Approximately $ 1500.00 to $ 3000.00 per tooth

Higher cost with complex situations

ADVANTAGES:

Most lifelike, natural appearing of all cosmetic restorations

Color changes possible

Less chipping than bonding

Extremely strong bonds to enamel

More conservative- less tooth removed than crowning

Lasts five to fifteen years

Usually placed above the gum line so gums are healthier

Teeth can be straightened and lengthened to create youthful look

DISADVANTAGES:

More costly than conventional bonding

More difficult for dentist to produce polished surface after contouring and reshaping in the mouth

More difficult to repair if the laminate cracks or chips

Irreversible procedure

ALL CERAMIC CROWNS

TREATMENT TIME:

Usually two appointments of approximately one hour per tooth. Expect to spend more time for more complicated situations.

PATIENT MAINTENANCE:

Crowns are esthetically designed to look and feel like real teeth. As with your natural teeth, however, care must be taken to avoid tooth fractures: biting on hard foods and objects like peanut brittle or ice is strictly forbidden. A caries-free or decay free diet (a routine that reduces intake of refined sugars) is imperative to prevent the cement that holds the crowns in place from dissolving and causing new cavities; Have a professional dental prophylaxis at least three times a year and use the sonic toothbrush and fluoride toothpastes regularly.

TREATMENT RESULTS:

Crowning can achieve color control, tooth shape and tooth size.

AVERAGE RANGE OF TREATMENT LIFE:

Longevity is related to fracture, problems related to gum problems and the hidden danger of decay.  The better the restoration fits the tooth and the bite, the longer it will last: longevity ranges from five to twenty plus years.

COST:

Approximately $ 1500.00 to $ 3500.00 per tooth: however, more costly in difficult and complex situations.

ADVANTAGES:

Teeth can be lightened or color changed to any shade desired.

The shape of the tooth can be greatly improved

Longest life of all esthetic/cosmetic restorations

Crowns can fracture

Anesthetic required

Original tooth structure is altered, possibly involving the nerve

If gum tissue shrinking occurs it can expose the margin of the tooth/crown edge allowing the possibility of an unsightly line at the  gum line

BEST MAINTENANCE ADVICE

Nothing lasts forever……there are three reasons why “perfect” restorations deteriorate over time:

Unfortunately most materials used in dentistry can chip or fracture

Every material has a wear and tear factor and so do most materials and items used in our daily lives

Cemented restorations are attached to the tooth with cements that can dissolve when exposed to oral fluids

Be careful when eating foods that tend to attack and dissolve the bond of the restoration to the tooth: mints, chewing gum, candies and other sticky refined carbohydrates can do just that!

Make sure you are not clenching or grinding your teeth or chewing hard foods, such as, ice, hard candies, tough jerky and other foods like these.

Wear a “bite guard” at night to further protect your porcelain edges!

REFERENCES

1. http://dentistry.uic.edu/depts/oralb/TeethBeautyBiologyHealth.htm, p. 1.

2. Patniak, V.V.G., J. Anat. Soc. India, 74-80, Anatomy of a Beautiful Face & Smile, p. 74.

3. http://www.beautyanalysis.com/mba_definitionoffacialbeauty_page.htm

4. http://dentistry.uic.edu/depts/oralb/TeethBeautyBiologyHealth.htm, p. 2

5. Ibid.

6. Wheeler, Russel, D.D.S., Dental Antomy and Physiology, p. 42.

7. Bastian, Gill, D.M.D., Applied Functional Orthopaedic and Orthodontic Therapy, p. 4.

8. Possellt, Ulf, L.D.S., D.M.D., Odont Dr., Physiology of Occlusion and Rehabilitation, p. XIII.

9. Shore, Nathan Allen, D.D.S.,  Occlusal equilibration and Tempromandibular Joint Dysfunction, p. 4.

10. Ibid # 8,