principles and practice of esthetic dentistry

2. CONTENTS:
 Introduction
 Definitions and classification
 Esthetic diagnosis and treatment planning
 Esthetic sequencing
 Perceptual aspects – the art of illusion
 Process of smile design and analysis
 Esthetic contouring
 Esthetics with composites
 Esthetics with ceramics
 Conclusion
2

3. INTRODUCTION:
 Smile—the perceiveness of one’s personality is said to be a God’s gift. Certain
issues might create discrepancies in this appearance, the role of a cosmetic
dentist is crucial in analyzing and crafting the desired smile.
 Scottish physiologist Charles bell (1774-1842) was quoted as remarking that the
thought is to the word that the feeling is to the facial expression.
 The focus of dentistry in the present times is not only the prevention and
treatment of diseases but on meeting the demands for better esthetics.
 Esthetic dentistry is emerging as one of the most progressive and challenging
branches of this field. Basically the smile is dependent on the musculature and
the presence of the teeth. But every person is not fortunate enough to have a
beautiful smile. The answer to the above problem is the esthetic dentistry which
has developed leaps and bounds with the latest technologies and materials.
3

4.  Esthetic dentistry is characterized primarily by the smile. The goal in the
creation of esthetic dental restorations is to stimulate, or improve upon, the
appearance of the natural dentition. The successful esthetic restorations must
integrate harmoniously with the whole of the face., not just with the
surrounding teeth.
 Smile designing is not only related to restorative dentistry , in fact it is an
interdisciplinary approach involving restorative, orthodontic, prosthodontic
and periodontal aprroaches.
4

5. DEFINITIONS:
Esthetics (adj. 1798)
 The branch of philosophy dealing with beauty.
 In dentistry, the theory and philosophy that deal with beauty and
beautiful, esp. with respect to the appearance of a dental restorations, as
achieved through its form and or color. Those subjective and objective
elements and principles underlying the beauty and attractiveness of an
object, design or principle.
Dental Esthetics
 The application of the principles of esthetics to the natural or artificial
teeth and restorations. (GPT 1999)
5

6. Esthetic Dentistry
 Can be defined as the art and science of dentistry applied to create or
enhance beauty of an individual within functional and physiological limits.
Cosmetic dentistry
 is application of the principles of esthetics and certain illusionary
principles, performed to signify or enhance beauty of an individual to suit the
role he has to play in his day-to-day life or otherwise.
Smile designing
 Is a process whereby the complete oral hard and soft tissues are studied
and evaluated and certain changes are brought about which will have a positive
influence on the overall esthetics of the face. These changes are governed by the
principles of esthetic dentistry
6

7. CLASSIFICATION OF SMILE:(Solomon)
 Depending on the nature of labial mucous
membrane
 papilla smile
 Gingival smile
 Mucosa smile
 Dependant on the lip component
 Straight smile
 Convex smile
 Concave smile
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8. ESTHETIC DIAGNOSIS & TREATMENT PLANNING:
 A meticulous esthetic diagnosis followed by a well- defined treatment
plan is the foundation of successful esthetic dental treatment. The
definitive treatment plan should address the treatment periods,
expenses, treatment sequencing and all aspects related to the function
and maintenance of the anticipated results.
1. Patient history :-
 Information should cover aspects of -medical history- allergic, systematic
disorders , pervious surgeries e.t.c
 Dental history- past dental experiences , apprehensions, expectations
e.t.c
 Personal and social history
8

9. 2. Clinical examination :-
 A clinical examination involves a through evaluation of facial and
temporomandibular components and assessment of occlusal relationship,
periodontal attachment, teeth and intra-oral soft tissues
 Facial components:- Face form
 Symmetry along the midline
 Relationships of various parts of the face
 Position of the lips and chin from frontal as well as lateral aspect
 Relationship of horizontal and vertical references of face with respect to teeth
and gums
 TMJ :-
 Palpated and auscultated for clicking
 Crepitus
 Hypermobility
 Deviation
9

10. OCCLUSION RELATIONSHIPS:-
 Occlusal pattern
 Type
 Contacts
PERIODONTAL ATTCHMENT:-
 Plaque
 Calculus
 Gingival inflammation
 Amount of attached gingiva
 Recession
 Hyperplasia of gingiva
TEETH:-
 Caries
 Existing restoration
 Discoloration
 Wear facets
10

11.  TOTAL SMILE ANALYSIS:
 Total smile analysis is a cumulative interference analysis, drawn by
interpreting and integrating various analysis like a visual, space profile
and computer analysis after performing the preliminary analysis.
12

12.  SPACE ANALYSIS:
 help to gauge the amount of space available during the treatment planning
stage(measure the widths of all teeth and to compare it with the space present
in the arch).
 Disproportionate space may be due to discrepancies in jaw and tooth size,
malformed teeth, missing teeth, malaligned teeth, etc
 Corrections of labiolingual inclinations and rotations of teeth by restorative
procedures will result in a change in the width space ratio due to the change of
angulation involved.
13

13.  PROFILE ANALYSIS:-
 straight orthognathic – normal profile.
 Any deviation from this should be recorded and considered in treatment
planning.
 Examination of the profile could be in the antero-posterior plane or in the
vertical plane.
 COMPUTER ANALYSIS:-
 Radiographic and photographic assessments can be used. Computer aided
technology has broadened the utility of radiographs and photographs in the
dental field.
 They give enlarged images of the photographic and radiographic outputs on the
screen without the involvement of any hard copies of photographs or
radiographs with multiple magnifications & at various angles.
 Esthetic enhancement with a change of arrangement , form , shape or color can
be demonstrated quickly.
14

14. COMPONENTS OF AN
ESTHETIC SMILE
Facial component
Hard tissues
Soft tissues
Dental component
Teeth
Gingiva
15

15. • Interpupillary line
• lips
Facial features that
play a vital role
16

16.  During a relaxed 'ideal smile', the upper lip exposes the cervical aspects of the
maxillary anterior teeth.
 The gingival margins of the maxillary central incisors should be symmetrical
and at the same height. Up to 3 mm of gingival exposure above the cervical
margins of the maxillary teeth is aesthetically acceptable .
 Beyond 3 mm results in a 'gummy' smile, requiring correction by orthodontic
or surgical intervention to avoid visual tension .
17

17. • Treatment modalities depend on the type of pathosis,
• hyperplastic gingivae  gingivectomy or crown lengthening
• recession  orthodontics or cosmetic periodontal plastic surgery using tissue
grafts or guided tissue regeneration membranes
• over eruption  orthodontic intrusion
• deficient pontic sites  ridge augmentation procedures
• skeletal abnormalities  orthognathic surgery.
18

18.  E-line or esthetic line is an imaginary line connecting the tip of the
nose to the most prominent portion of the chin on the profile, ideally the
upper lip is 1-2 mm behind and the lower lip 2-3mm behind the E-line. Any
change in the position of the E-line indicates the abnormality in the upper or
lower lip position.
19

19. Vital Elements of Smile Design- Dental Components
Tooth components
Dental midline
Incisal lengths
Tooth dimensions
Zenith point
Axial inclinations
Interdental contact
Embrasures
SPA
Symmetry and balance
Soft tissue components
Gingival health
Gingival levels and harmony
Interdental embrasure
Smile line
20

20. MIDLINE :
 Dental midline should be collinear with facial midline.
 Vertical contact interface between the 2 centrals
 Perpendicular to the interpupillary line and parallel to facial midline
 As long as the midline is parallel with the long axis of the face , midline
discrepancies up to 4mm is not considered unaesthetic.
 But canted midlines aren’t considered esthetic.
Image of smile where the facial and
dental midline do not line up.
21

21. A slanted mid line, or a dental
mid line that is placed obliquely
in relation to the facial mid line,
will always distort the
symmetry, even placed in
exactly the correct position.
It looks even more
unpleasant when it is slanted
and shifted to the side at the
same time.
22

22. INCIAL LENGTHS( EDGE POSITION) :
 Most important determinant in smile creation as once set, it serves as a
reference point for establishing the proper tooth contours and gingival
levels.
 IMPORTANT PARAMETERS 
 Degree of tooth display
 Phonetics
 Patient input
23

23. • The normal tooth display at rest is about 2.5 to 3mm.
• If the overall display of teeth is less than 2.5 mm then orthodontic
extrusion or orthognathic surgery has to be considered.
• In teeth with both angles fractured, this can serve as a guide in deciding
placement of incisal edge.
• But this is only true for young individuals.
Degree of tooth display
Image of the lower one third showing
tooth display at rest. The display was measured
to be between 2.5 to 3 mm.
24

24. PHONETIC REFERENCES:
 Phonetics play a part in determining maxillary central incisor design and
position.
 ‘F’ and ‘V’ sounds are used to
determine the tilt of the incisal third
of the maxillary central incisors and
their length.
 ‘E’  incisal edge should be
halfway between upper and lower
lip
25

25.  The ‘M’ sound is used to achieve relaxed rest position and repeated at slow
intervals can help evaluate the incisal display at rest position .
 ‘S’ or ‘Z’ sounds determine the vertical dimension of speech. Its pronunciation
makes the maxillary and the mandibular anterior teeth come in near contact
and determine the anterior speaking space.
26

26. TOOTH DIMENSIONS
 Correct dental proportion is related to facial morphology and is essential in
creating an esthetically pleasing smile.
 CENTRAL DOMINANCE dictates that the centrals must be the dominant teeth
in the arch and they must display pleasing proportions.
 The proportions of the centrals must be esthetically and mathematically
correct  the width to length ratio  4:5
 The shape and appearance of the centrals influences the placement of laterals
and canines.
27

27. GUIDELINES FOR CORRECT PROPORTIONS…
GOLDEN PROPORTION (lombardi)
RECURRING ESTHETIC DENTAL PROPORTION
(ward)
M PROPORTION (methot)
CHU’S ESTHETIC GAUGE
28

28. Golden Proportion
 is expressed in numerical form and
applied by classical mathematicians
such as Euclid and Pythagoras in pursuit
of universal divine harmony and
balance.
 It has been applied to a lot of ancient Greek and Egyptian architecture and
may be expressed as the ratio 1.618:1.
 If the ratio is applied to the smile made up of the central, lateral incisor and
the mesial half of the canine, it shows that the central incisor is 62% wider
than the lateral incisor which in turn is 62% wider than the visible portion
of the canine which is the mesial half, when viewed from the front.
29

29. RECURRING ESTHETIC DENTAL PROPORTION (ward)
• The successive width proportions when viewed from the facial aspect should
remain constant as we move posteriorly from midline.
• This offers greater flexibility to match the tooth proportions to the facial
dimensions.
• M PROPORTION
• CHU’S ESTHETIC GAUGE  Computer software
Image showing close to an 80% width to-
length ratio and optical width of the central relative
to the lateral and the lateral relative to the
canine. Note that esthetic percentages do not follow
the golden proportion, especially the canine.
30

30. INDIVIDUAL TOOTH DIMENSIONS…
 MAXILLARY CENTRAL INCISOR-
 focal point
 Length 10-11 mm
 Width 75-80% of length
 MAXILLARY LATERAL INCISOR-
 Playful part of smile
 Provide individuality
 Never symmetrical
 Influence gender characterization
31

31.  MAXILLARY CANINES-
 Critical point in creating a pleasing smile
 Junction between the anterior and posterior teeth
 Supports frontal muscles
 Size and shape of buccal corridor depends on the canine
Note :-
Centrals wider than laterals by 2-3mm
canines by 1-1.5mm
Canine wider than lateral by 1- 1.5mm
Canine and central are longer than lateral by 1-1.5mm
 MAXILLARY BICUSPIDS-
 Important role in arch design
 Fill the buccal corridor
32

32. BUCCAL CORRIDOR
 In an esthetic smile there is what has been termed negative space, which is a
small space between the maxillary posterior teeth and the inside of the cheek.
 In an esthetic smile the percentage visibility decreases as we go more posteriorly .
If there is any malocclusion or discrepancy in arch form leads to loss of esthetics.
33

33.  If the space appears excessive when the patient is smiling, a small amount of the
space can be filled by increasing the buccal contours of the maxillary posterior
restorations.
 If conservative additive or subtractive (i.e., esthetic contouring) techniques will
not work esthetically, then orthodontics should be considered.
Gives depth & mystery to the
smile
Indicates occlusal
disturbance or inadequate
restorative dentistry
34

34. Interdental contact areas & points
Longest contact –
between central
incisors
Shortest contact-
between lateral &
canine
Interdental contact points
– where the interdental
contact area ends
35

35.  The contact points of the maxillary teeth are relevant for ensuring optimal 'pink
aesthetics' for patients with a high smile line (or visible cervical margins).
 the '5 mm rule', states that when the distance from the contact point to the
interproximal osseous crest is 5 mm or less, there is complete fill of the gingival
embrasures with an interdental papilla.
 For every 1 mm above 5 mm, the chance of complete fill is progressively reduced
by 50%.
Black triangle
36

36. Interdental contact area can be moved apically to close the
gap
37

37. GINGIVAL ZENITH OR HEIGHT OF CONTOUR:
 The apex of the gingival height of
contour on the anterior teeth is
called zenith point.
 Central : distal third
 Lateral: central
 Cuspid : distal third
 Bicuspids : central
38

38.  Nicely scalloped gingival contours – the pleasing relationship of the
zenith points should create a shallow reverse triangle at zenith point
of lateral incisor – 0.5 – 1mm incisally.
39

39. INCISAL EMBRASURES
 In an esthetic smile, the edges of the maxillary anterior
teeth follow a convex or gull-wing course matching the
curvature of the lower lip.
 Reduced incisal embrasures and leveling of the gull-wing
effect as in a straight smile line is associated with aging.
40

40. Smallest & sharpest between the
central incisors
90º between premolars in
young unworn dentitions
In aged / worn dentition – embrasures are smaller or disappear –
teeth need to be lengthened & embrasures need to be recreated
41

41. Sex, age and personality
Sex
• Maxillary
incisors
• Females –
round, smooth
and delicate
• Males –
cuboidal and
vigorous
Age
• Youthful teeth-
unworn incisal
edge, defined
embrasures,
high value
• Aged teeth-
shorter ,
minimal
embrasure and
low value
Personality
• Maxillary
canine
• Aggressive,
hostile- long
fang like
• Blunt, rounded,
short cusp-
passive and soft
42

42. Soft tissue component of smile
 The lips frame the teeth and gingiva. The gingiva frames the teeth. The ratio of
tooth structure to the amount of gingival and labial tissue should be
harmonized to prevent an over-dominance of any one element.
Gingival Line :
 GAL- gingival aesthetic line – the ideal gingival line from the cuspid to the
central incisors intersects the dental midline at an angle >45° but <90°.
 The key esthetic issue is that the gingival line for the anterior teeth should be
relatively horizontal to the horizon and relatively symmetric on both sides of
the midline.
 In an esthetic smile, the volume of the gingiva from the apical aspect of the free
gingival margin to the tip of the papilla is about 40% to 50% of the length of
the maxillary anterior tooth and fully fills the gingival embrasure.
43

43. 44

44. Image demonstrating the measurements
of the ideal gingival scallop, with the
percentages showing the papilla length relative
to tooth length.
Image showing the gingival line on
the same patient. Note the lateral and central
apical position of the gingival margin is on a
straight line that is completely horizontal.
45

45. Periodontal biotype and bioform
 The human tissue biotype is classified as thin, normal or thick.
 The thin periodontal biotypes are friable, escalating the risk of recession
following crown preparation and periodontal or implant surgery.
 This is particularly significant for full coverage crowns for the following
reasons.
1. Firstly, the thin gingival margins allow visibility of a metal substructure
(either porcelain fused to a metal crown or implant abutment), thereby
compromising aesthetics in the anterior regions of the mouth. In these
circumstances, all-ceramic crowns, or ceramic implant abutments are a
prerequisite to avoid aesthetic reproval.
2. Secondly, due to the fragility of the thin tissue, delicate management is
essential for avoiding recession and hence visibility of subgingivally
placed crown margins at the restoration/tooth interface.
46

46. ESTHETIC TREATMENT PLANNING AND
SEQUENCING
 integral part of treatment planning
 Treatment procedure which will be programmed or charted
 FINAL CASE PRESENTATION:- three basic methods
1. Mock up - with soft tooth colored wax or composite resin- Direct composite
resin placement along with the use of intraoral markers ( provide a visual three
dimensional means for the patient to see the final result prior to committing to
treatment). The functional movements in the mouth can also be checked at this
time to determine any occlusal obstruction or difficulties.
47

47. 2. Diagnostic wax-up or study casts- This wax up can be evaluated by the
patient directly on the diagnostic casts of the articulator and also intraorally with
the use of acrylic overlays and acetate matrices.
3. Computer imaging- Digital imaging takes advantage of contemporary
technology. In a particular case, esthetic enhancement with a change of
arrangement, form, shape and color can be demonstrated quickly.
48

48. COLOR:
 Colour cant be perceived without light (electromagnetic energy).
 visible light spectrum of light - 380nm to 760nm.
 ability to stimulate the cells in the retina which is interpreted by the brain,
discerning the sense of colour.
 Clark stated that “color, like form, has three dimensions”.
→ Hue which is the name of the radiant energy.
→ Chroma, which is the saturation of the hue
→ Value, which is the relative lightness or darkness of the colour.
49

49.  MUNSELL color order helps to
visualize and organize color.
 HUE- in Munsell’s words, “it is that
quality by which we distinguish one
color family from another. Generally
there are six hue families, violet,
blue, green, yellow, orange and red.
 For example, in the vita shade guide
there are four hues A, B, C and D
denoting reddish brown, reddish
yellow, grayish and reddish grey
respectively.
50

50.  CHROMA - in Munsell’s words, “it is the
quality by which we distinguish a strong
color over weak ones”. Human teeth fall into
the yellow to yellow red area of the Munsell
color order system. Pale colours have a low
chroma whereas intense colors have high
chroma.
 VALUE - value or brilliance is the relative
blackness or whiteness of color. On a scale
of black to white, white has “high value”,
black a “low value” and midway between
the black and white is the medium grey.
Value is the only dimension of colour that
can exist by itself.
51

51. Principles of Shade Selection
1. Teeth to be matched must be clean
2. Remove bright colors from field of view
- makeup / tinted eye glasses
- bright gloves
- non neutral operatory walls
3. View patient at eye level
4. Evaluate shade under multiple light sources
5. Make shade comparisons at beginning of appointment
6. Shade comparisons should be made quickly to avoid eye fatigue
52

52. Commercial Shade Guides
 Most convenient and common method of making shade selections
 Guides consist of shade tabs
 Metal backing
 Opaque porcelain
 Neck, body, and incisal color
 Select tab with the most natural intraoral appearance
 Vita Classic
 Vitapan 3D –Master
 Extended Range Shade Guides
53

53. Vita Classic Shade Guide
 Tabs of similar hue are clustered into
letter groups
 A (red-yellow)
 B (yellow)
 C (grey)
 D (red-yellow-gray)
 Chroma is designated
with numerical values
 A3 = hue of red-yellow, chroma
of 3

54. Manufacturer recommended sequence for shade matching
1. Hue Selection
2. Chroma Selection
3. Value Selection
4. Final Check / Revision
 Four categories representing hue
 A, yellow-red
 B, yellow
 C, gray
 D, red-yellow-gray
 Operator should select hue closest to that of natural tooth
 Use area of tooth highest in chroma for hue selection
 Difficult to select hue for teeth low in chroma
56

55.  Hue selection has been made (B)
 Chroma is selected from gradations within the B tabs
 B1, B2, B3, B4
 Several comparisons should be made
 Avoid retinal fatigue
 Rest eyes between comparisons (blue-gray)
 Use of second, value ordered shade guide is recommended
 Value oriented shade guide
 B1, A1, B2, D2, A2, C1, C2, D4, A3,
D3, B3, A3.5, B4, C3, A4, C4,
 Value best determined by squinting with comparisons made at arms length
 Decreases light
 Diminishes cone sensitivity, increases rod sensitivity
 Tooth fading first has a lower value
57

56. OPACITY & TRANSLUCENCY:
 As light strikes a surface, it is either totally reflected, totally absorbed or a
combination of both.
 Opaque objects reflect all or most of the light that is incident on them
whereas transparent objects transmit all of the light that is incident on
them.
58

57.  Translucency, in effect is the three dimensional facial relationship or
representation of value.
Highly translucent teeth tend to be lower in value, since they allow light to be
transmitted through the teeth, while opaque teeth have higher values.
 To mimic natural teeth the effective use of restorative materials should largely
depend upon mimicking the translucent or opaque effect.
59

58. METAMERISM:
 The change in color perception of two objects under different light sources is
called metamerism.
 This can be attributed to the difference in the radiant energy of two different
wavelengths of light. The standardization of lighting condition during shade
matching diminishes the effect of metamerism.
60

59. • The emission of light by an object at a different wavelength from that of an
incident light is called fluorescence.
• The emission stops immediately on removal of incident light. Teeth
fluoresce with a stimulus in range of 340nm-410nm. This spectrum is the
blue range.
• Thus, according to the principle of additive color, the emitted blue light
acts with the yellowness of the tooth to produce a white tooth.
• Fluorescing pigments incorporated in the ceramic restorations by the
ceramist and in the composite restorations by the manufacturer may thus
be advantageously used in altering the perception of final result.
GLOSS-
Gloss is an optical property associated with a smooth surface that produces
lustrous surface appearance and reduces the effect of color differences.
FLUORESCENCE
61

60. PERCEPTUAL ASPECTS - THE ART OF
ILLUSION
 Illusion is a figament of imagination where a perception of an object is
created.
 FUNDAMENTALS AND PRINCIPLES-
 The art of creating illusion consists of changing perception, to cause an
object to appear different from what it actually is.
 Teeth can be made to appear smaller, larger, wider, narrower, shorter,
longer, younger, older, masculine or feminine.
62

61. • Illusion works on two basic principles, which are the illusion of principles of
illumination and the principle of line.
• The most important of these is the perception that light approaches and dark
recedes. This is termed as “principle of illumination”.
• The second artistic prediction of great importance in dentistry is the use of
horizontal and vertical lines and ridges.
Horizontal lines make the objects appear wider and vertical lines make the object
appear longer. This is termed as the principle of line.
The artistic predilection exhibited in the principle of illumination can be
maintained to change the size, shape and the overall form of the tooth through
illusions.
63

62. Narrowing illusion
Widening illusion
64

63. Lengthening illusion
Shortening illusion
65

64. LAW OF TOOTH FACE:
 The face of a tooth is that area on the facial form on both anterior and
posterior teeth, that is bound by the transitional line angles as viewed
from the facial i.e.., labial or buccal aspect.
 These transitional line angles mark the transition from the facial surface
to the mesial, distal, cervical and incisal surfaces.
 The tooth surface slopes lingually in the mesial and distal region while it
slopes cervically from the line angles towards the root surface.
 Whenever there is no transitional line angle demarcating the incisal
portion of the facial surface, the face is bound by the incisal edge as the
occlusal tip.
66

65.  The law of the face implies making dissimilar teeth appear
similar by making the apparent faces equal.
 The apparent face should be manipulated, not the actual face. This is
more importantly in the canine and the posterior as the “apparent face”.
 The transitional line angles are relocated so that the apparent face looks
equal.
 Similar faces produced attract light and appear highlighted while the
dissimilar areas that are in a shadow appear to recede.
67

66. ESTHETIC CONTOURING
INDICATIONS
 Alteration of tooth structure
 Correction of developmental
anomalies
 Minor orthodontic problems
 Removal of stains & discolorations
 Periodontal problems – trauma
from occlusion
 Bruxism
 Reshaping & rounding of the
corners of CI & LI to give more
youthful look.
CONTRAINDICATIONS
 Hypersensitivity of teeth.
 Large pulp canals
 Thin enamel
 Deeply pigmented stains
 Occlusal interferences
 Susceptibility to caries
 Extensive anterior crowding &
occlusal disharmony
68

67. TECHNIQUES OF ESTHETIC RECONTOURING:
Achievement of illusions
 The purpose of planning is to determine how to achieve an illusion of
straightness. This process must include different views and perceptive.
An optical illusion must work most effectively in the position from which
most people would be viewing the patient
 Developmental grooves play important role in creating illusion.
 If the grooves are placed more apart illusion of more wide teeth can be
created & vice versa.
 If there is dark pigmentation in the periphery and light in central portion
of the facial aspect of tooth an illusion of narrow teeth can be created.
69

68. Angle of correction
 A lower incisor that actually or apparently, extends above the lower incisal plane is quite
noticeable.
 The angle of view is important specially in shaping lower teeth. Because of the angle of
view, an anterior teeth which is in linguoversion appears to be much more prominent
than the one in labioversion.
 To contour the tooth in linguoversion, its incisal edge should be beveled lingually.
Reduction
 reshaping of the natural dentition must always be in relationship to the lip position in
both speaking and smiling.
 In rare cases it may be necessary to desensitize the tooth - sodium fluoride or a dentin
sealer.
 with the use of water, it is often possible to see a slight color shift before the enamel is
completely penetrated. The last few layers of enamel are more translucent so that the
yellow dentin becomes more visible. Enamel removal should be stopped as soon as color
shift is observed and hopefully before
 Anterior teeth in the lower arch should be shortened only to the level where they still
occlude in protrusive movements.
70

69.  Reduction is accomplished by carefully shaping
the marked areas with the bulk reduction
diamonds except for the lower anterior teeth.
Bulk reduction in these teeth should be done
with fine finishing diamonds at high speed.
 Final shaping on the mesial, distal, incisal and
embrasure is done with the thin and the extra
thin diamond points, because their shape allows
for better access to these areas. This is followed
by the white or green finishing stone.
71

70. ALTERATION OF TOOTH FORM:
 A canine that has drifted or been repositioned into the space of an extracted or a
congenitally missing lateral incisors can sometimes congenitally be reshaped to resemble
the missing tooth.
 Another example is to remove the part of the lingual cusp and reshaping of the labial
surface of a first bicuspid so that it resembles a cuspid.
72

71. PEG SHAPED LATERALS: Treatment
options
1. No treatment, patient not concerned
2. Orthodontic treatment first to align the teeth in
the arch
3. Direct composite bonding onto peg laterals
4. Indirect composite placement
5. Bonded crowns
6. Porcelain bonded to metal crowns (Bello 1997)
7. Crown lengthening surgery to get better gingival
heights.
8. Extractions and implant placement
9. Combinations of treatment in different
sequences
73

72. ESTHETICS WITH COMPOSITES
 The conservative treatment approach is best collaborated with the use of
composite due to their ability of bonding to many surfaces of natural teeth.
 This has opened many avenues for the use of these materials for esthetic
benefits in cases that probably could not be treated effectively or at all in their
absence.
 The results with these materials are quick, esthetic, economical, repairs
are easy and the material does not require unnecessary tooth reduction for
their placement.
 In most instances the final results are all in the control of the dentist without
the involvement of laboratory technicians thus providing the dentist an
opportunity to exhibit his skills.
74

73. BENEFITS OF DIRECT COMPOSITES:
 1. Preserve sound tooth structure
 2. Can be placed directly onto the tooth surface
 3. Can place as a type of direct composite veneer
 4. It is a conservative restoration
 5. Can easily change the emergence profile and angle
 6. Can alter the shapes and length of the tooth
 7. Can close diastema.
 8. Can be used as an interim restoration in an adolescent and added to as
the gingival heights matures
 9. Can be repaired easily
 10. Can be polished and repolished to a high shine
 11. Long lasting
 12. Not expensive treatment option
75

74. DISADVANTAGES OF DIRECT COMPOSITES:
 1.Can chip and break
 2. Can discolor if older composite used
 3. Can develop marginal leakage (Walls 1988)
 4. Can pick up stain easily in those patients who smoke and have poor oral
hygiene
 5. Can have a deleterious effect on gingival health on patient with poor oral
hygiene (Walls 1988)
76

75. CONSIDERATIONS FOR PREPARATION
DESIGN FOR ANTERIOR TEETH
• Though the preparation design for composite resins do not follow a
prescribed pattern, they are essentially made as conservative as
possible, leaving as much enamel as possible for effective bonding.
• This is done keeping desired final esthetics of the restorations in mind.
• The preparation design for anterior composite restorations should
encompass
1. elimination of decay,
2. function and longevity and
3. esthetic predictability.
77

76.  The facial form of all anterior teeth can be divided into various facial planes,
which converge or diverge from each other.
 These planes reflect or refract light and give a texture to the facial surface.
 The areas between any two planes are relatively prominent and hence
extensions of the margins of the preparation should be kept away from those
prominent areas.
 Extension for functional esthetics(EFE) is achieved using a long bevel
extending a few millimeters, from the cavity margin and ending on a relatively
flat area on one of the planes. The EFE ensures that the margin of the
restoration overlays the defects.
The esthetic advantages are:-
 Successful masking of the defect
 Better marginal adaptation
 Natural transition of shade between composite and tooth
 Ease of finishing and texturing.
78

77. PLACEMENT OF COMPOSITE FOR
CARIOUS TEETH:-
 When the caries involves the labial surface of the EFE, follow the general
guidelines explained earlier, following the facial planes.
 However in cavities having palatal access, leaving a thin shell of enamel of
facial surface is not recommended as it is difficult to blend the composite
restoration with the rest of the tooth.
 In such cases the labial unsupported enamel is reduced and the composite
is extended on the facial surface.
 If the carious lesion is large , then a full facial veneer preparation may be
the best option for optimal esthetic results.
79

78.  During the placement of composite in the proximal areas, a mylar/metal strip
is placed between the preparation and adjacent tooth while acid etching and
bonding.
 A small amount of flowable composite is placed along the wall and cured.
 A layer of an opaque hybrid composite is placed more on the palatal half of the
restoration and also in conditions where palatal wall is absent.
 This blocks the path of light passing through and through giving a grey
translucency to the restoration
80

79. CLASS III RESTORATION
 Shade selection for the class III composite can be both time consuming and
frustrating.
 The major problem is choosing the shade that will actually match after you
have inserted and finished the restoration.
 Typically, the first thing you do is place a sample of intended material on the
tooth to be restored.
 The difficulty is to anticipate the correct amount of material thickness so the
final result will match.
 A good method of accomplishing this is to vary the thickness of sample by
pressing harder on one end by mylar strip so you will get a gradation of colour,
and therefore get a better indication of just how close your shade will match
with the estimated thickness.
81

80. CLASS IV RESTORATIONS
 Those, including chipped or fractured teeth, are one of the top reasons for using
composite resins.
 Frequently bonding is the ideal solution, providing both an immediate answer to
an esthetic emergency and a long term, low cost restoration.
CLASS V RESTORATIONS
 Generally microfill composites are choice of materials but recently
nanocomposites are being used as they provide strength as well polishabilty
similar to microfilled.
 When making a shade selection for class V restorations, first note patient’s lip
line.
 This is particularly important for patients with a medium lip line where the
incisal most margin will show during a wide smile.
 there is a shadow created with the lip line that tends to emphasize the grey
shades. Therefore avoid translucent shades if possible, and select the more
opaque shades for better blending.
82

81. LABIAL VENEERS
 The quickest and the most economic method of obtaining an esthetic tooth
transformation is through the direct resin labial veneer.
 The best candidate for the direct resin veneer is the monochromatic shaded
tooth, since multicolored restorations are much more easily constructed in the
laboratory.
83

82.  Minor malalignment can be corrected with minimal reduction of tooth
structure by changing the tooth form in the preparation design to allow the
composite restoration to recreate the desired form.
 In some of the cases, the preparation design resembles the one made to treat
the minor fractures.
 Multiple malaligned teeth are viewed in totality and then individually.
 The most difficult tooth to be treated is marked and may be the ultimate guide
on which the corrective treatment may be used, as it gives an idea of the
limitations within which the dentist has to give an esthetic final result.
84

83. PLACEMENT OF COMPOSITE FOR DISCOLOURED
TEETH
 Discolored teeth are usually challenging to treat.
 The dentist has to consider the masking of the dentin surface not only at the
facial surface but at the cervical margins and incisal edges.
 A facial veneer is usually preferred for such situations.
 The preparation should allow a uniform thickness of composite to create a
polychromatic appearance in the final result.
 In cases of severe discoloration the depth of preparation should allow an
additional thin layer of opaque composite to mask the dark dentin.
85

84. • In some cases the incisal edges need to be covered with composite
extending on the palatal surface.
• The margin of the restoration should be kept subgingival whenever
possible.
• Intracrevicular margin placements in discoloured teeth are unavailable
for polishing hence restoration margins have to be superiority finished,
for easy maintenance.
86

85. PLACEMENT OF COMPOSITE FOR
CLOSING SPACES
 Diastema may be manifested due to microdontia, discrepancy between tooth
size and the available ridge and also due to variation in the tooth morphology.
 Although some natural spaces may be esthetically and phonetically acceptable,
others are not, and need corrective restorative procedures.
 cases where the size of teeth is normal and a diastema still exists, restorative
creations using principles of illusion is recommended.
87

86.  Boundaries of these space are assessed apico-coronally and mesio-distally as
they will differ with the location of the interdental papilla and the proximal
contours of the teeth.
 In periodontally treated cases, there could be papillary loss resulting in the
back triangle effect.
 These closing spaces in such cases may pose a challenge as the dentist may
have difficulty to maintain the tooth form, tooth preparations as well as allow
good gingival contours for favorable gingival response.
 Sometimes an excessive frenal tissue makes it difficult for the dentist to
restore this area and a frenectomy may be advised in some cases.
88

87.  When diastema is small (2mm) – no tooth
preparation required.
 Diastema between 2 angle-4mm – EFE
should be given on the proximal surface of
the labial curvature of the tooth.
 The extension preparation is close to the
gingival margin and follows the contours of
the interdental papilla to end on the palate-
proximal line.
 diastema larger than 4mm-- a similar
preparation coupled with recontouring of the
other proximal surface of the tooth to
maintain tooth proportions and form may be
required.
89

88. Diastema are filled in one teeth at a time. Acelluloid matrix is effectively used
to get the desired contour.
In the diastema, opaque composites are used to build up a palatal wall
followed by placement of hybrid composites of the desired shade on the palatal
and cervical aspect of the cavity. Microhybrid or microfilled composites are
then used as the final layer
90

89. Overlapping/ mal-aligned central
incisors:
 The main objective is correcting overlapping incisors to remove as much as
possible of the tooth structures that overlaps the adjacent tooth by contouring the
labial aspect of the labially malposed tooth.
 This straightens the portion that overlaps the adjacent tooth and makes the long
axis of teeth more parallel to each other.
 The incisal embrasure between the teeth is reopened to at least 0.25 to 0.50mm
length.
91

90. 92

91. ESTHETICS WITH CERAMICS
 In many dental practices, the ceramic crowns and bridges are one of the most
widely used fixed restorations.
 This has resulted part from technologic improvements in the fabrication of
restoration by dental laboratories and in part from growing amount of cosmetic
demands that challenge dentists today.
 Metal ceramic and all ceramic restorations have excellent esthetic potential.
 All ceramic restorations are characterized by a dentin like core which makes it
possible to mimic the translucency of natural teeth.
 They are biocompatible with the gingival tissue and exhibit excellent marginal
fit due to newer thermoplastic processing while some exhibit wear resistance
similar to enamel.
93

92. PRE-OPERATIVE ANALYSIS
 A preoperative model would help in determining the length, the labio-lingual
thickness, the convexity and taper of tooth.
 The position of the cingulum and occlusion will help to determine the extent
of preparation. X-rays help in determining the pulpal morphology and
crown-root ratio.
94

93. INDICATIONS OF METAL CERAMIC CROWNS
 Tooth requiring full coverage with high demand for esthetics.
 Retainer for fixed partial denture.
 Extensively destroyed teeth as a result of caries, trauma, or existing
previous restorations with a need for superior retention and strength.
 Need to re-contour axial surface or correct minor malocclusions.
CONTRAINDICATIONS
 Patients with active caries or untreated periodontal disease.
 Young patients with large pulp chambers.
 When an intact buccal wall is present.
 When the use of more conservative retainer is possible.
95

94. ADVANTAGES
 Combines the strength of all metal crown with the esthetics of an all
ceramic crown.
 Excellent retentive qualities as axial wall is included.
 Easy correction of axial forms.
DISADVANTAGES
 Removal of substantial tooth structure.
 Subject to fracture because porcelain is brittle.
 Difficult to obtain accurate occlusion in glazed porcelain.
 Shade selection can be difficult.
 Inferior esthetics compared to all ceramics.
 Expensive.
96

95. ALL CERAMIC RESTORATIONS:
Indications
 High esthetic requirement.
 Considerable proximal caries where the tooth can no longer be restored by
composite resin.
 Incisal ridge reasonably intact.
 Favorable distribution of occlusal load.
 Contraindications
 When superior strength is required then metal ceramic crown is more
appropriate.
 High caries index.
 Insufficient coronal tooth structure for support.
 Thin teeth faciolingually.
 Unfavourable distribution of occlusal load.
 Bruxism.
97

96.  Advantages
 Esthetically unsurpassed
 Good tissue response even for subgingival margins.
 Slightly more conservative of the facial surface as lack of reinforcement by metal
substructures.
 Disadvantages
 Reduced strength compared to metal ceramic crowns.
 Proper preparation extremely critical
 Least conservative preparation.
 Brittle nature of material.
 Can be used as single restoration only
98

97. Goals for achieving maximum esthetics…
Tooth
preparation
• Adequate tooth prep to avoid
unaesthetic contours.
• Allows sufficient bulk of the material
Gingival
retraction
• Harmony with the adjacent
periodontium
• Emergence profile highly esthetic
impression
• Correctly reproducing the finish lines
• Accurate for better results
99

98. VENEERS
 It is a layer of tooth colored material that is applied to a tooth to restore
localized or generalized defects and intrinsic discoloration.
 INDICATIONS:
 Discolorations
 Enamel defects
 Diastema
 Malpositioned teeth
 Faulty / poor restorations
 Aging
 Wear patterns
 Malformed lateral incisors
100

99. CONTRAINDICATIONS:
 Ability to etch enamel – deciduous & fluoridated teeth
 Bruxism
 Available enamel is thin
 Teeth with severe crowding
101

100. TYPES …
1. Directly fabricated veneers- These are composite resin materials applied to the
tooth surface free hand by clinician.
2. Indirectly fabricated veneers- Those are labio rotary fabricated veneers
developed on the cast of the patient mouth, this category can be further
subdivided to the material used-
 Composite
 Porcelain
Two types of esthetic veneers exist-
 Partial veneer- Are indicated for the restoration of localized defect or area of
intrinsic discoloration.
 Full veneers- Indicated for the restoration of the generalized defect or area of
intrinsic staining involving the majority of the facial surface of the tooth.
102

101. PORCELAIN LAMINATE VENEERS:
 ADVANTAGES:
 Color
 Bond strength
 Periodontal health
 Resistance to abrasion
 Inherent porcelain strength
 Resistance to fluid absorption
 esthetics
 DISADVANTAGES:
 Time
 Repair is difficult once luted
to enamel
 Technique sensitive
 Difficulty in color
modification
 Tooth preparation
 Fragility of porcelain
 Cost is high
103

102.  Enamel reduction must be considered from five
different aspects:-
 Labial reduction – 0.3 mm at cervical, 0.5mm in middle , 0.7 mm in
incisal ; chamfer finish line
 Interproximal extension - continued from the distal papilla tip to the
distal of the contact zone
 Sulcular extension – 0.5 mm supragingingival or 0.05 to 0.1 mm
subgingival
 Incisal or occlusal modification- 0.75 to 1mm ,
 Lingual reduction – butt joint of incisolingual junction
 IMPRESSION
104

103. CONCLUSION
 The crafting of an ideal smile requires analyses and evaluations of the face, lips,
gingival tissues, and teeth and an appreciation of how they appear collectively .
 Such an ideal smile depends on the symmetry and balance of facial and dental
features. The color, shape, and position of the teeth are all part of the equation.
Recognizing that form allows function and that the anterior teeth serve a vital
role in the overall health and well being of the patient is paramount.
 Using a comprehensive approach to diagnosing and treatment planning of
esthetics can help achieve the smile that best enhances the overall facial
appearance of the patient and provides the additional benefit of enhanced oral
health. All these equations and proportions do not still adequately hold good
toward restoring an ideal smile.
105

104. 106