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Philosophy of Treatment Planning and Restoring the Natural Smile – Helping Patients Decide Their Aesthetic Ideal

April 1, 2006
by Scott Arne, DDS, FAGD


In recent years, there have been many technological and procedural developments in “aesthetic” or “cosmetic” dentistry. Tooth whitening, various forms of marketing by dentists and manufacturers along with “reality” makeover TV shows, have produced an increased public awareness of restorative and cosmetic options. All this has created a consumer demand for what has time and again become merely a commercial product offering: “The Perfect Smile.”

This makeover mentality can ultimately result in an overly simplistic and “cookie cutter” approach, in which a clean slate is invasively prepared for six to ten indirect veneers or crowns without regard to functional occlusion or existing aesthetics. Insight into patient expectations, personality or actual need is for the most part overlooked. I believe a more personalized approach that capitalizes on existing structure, and creatively alludes to artistic aesthetic principles without rigidly adhering to them, can produce a more harmonious and natural aesthetic result, which ultimately, is more satisfying to the patient.

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Classic aesthetic principles, such as the “Golden Proportion,” date back to the Greeks Pythagoras in 500 BC and Euclid in 300 BC. This division of line (1.61803:1) in which the shorter section is 62% of the larger can be seen in architectural examples such as the Parthenon and other classical buildings.1 Leonardo da Vinci (1451-1519) demonstrated the interrelation and harmony of human anatomy components informed by these same ideals. We see these principles employed in dentistry with distribution of length and width of teeth, embrasure design, tissue contouring and other symmetrical principles to produce a uniform and “perfect” aesthetic result.2

These idealized results often are achieved by relying on a complete replacement of the smile, which has little regard for the previous natural characteristics of the original dentition. The only reference to the entire facial countenance is all too often just a source for geometric reference points such as the interpupillary and sagittal planes.

In this scenario there is little progressive evolution of composition and character based on the actual patient. Cosmetic dentistry envisions the lips as a frame surrounding but isolating the teeth from the patient’s total expression. The initial aesthetic design is frequently created by a technician who produces, not an individual composition based on knowledge of the patient, but a proposal based on his or her own ideal. This can only be modified in small stages until doctor and patient acquiesce. This all too often results in an overly symmetrical ideal that lacks an organic relation to both the individual patient and to the objective reality of nature.

Frequently, these efforts are accentuated with a shade that is neither natural nor appropriate. The smile becomes the focal point of the face rather than a harmonious component of an overall personal unity. This can set up an eventual cosmetic backlash. Patients, complimented on their obvious dental work and not their overall appearance, in time react negatively.

I propose a more thoughtful and subjective aesthetic analysis utilizing our full armamentarium; embracing minimal invasiveness; addressing each patient’s personality and expectations while avoiding overly generic treatment. Aesthetic dentistry should consider the smile as simply one part of the patient’s total expression.

Recognition of the difference between mechanical and organic principles is called for where strict application gives way to allusion. Built into the patient’s entire countenance, rather than built over it, is proportional harmony with supple Hogarthian curves and a natural effect. It is therefore important to recognize where subtle existing characteristics play an important role in a natural and personal aesthetic.

In 2004, Mahshid, Khoshvaghti, Varshosaz, and Vallaei found that the Golden Proportion does not exist between perceived maxillary anterior tooth widths of individuals with an aesthetic smile, thus indicating that the strict golden proportion is not always a common factor in aesthetic smiles.3 Through artistic license, the rule of golden proportion becomes a useful tool to aid success, rather than a rigid dogma meant to ensure it. While we are informed by architectural and mathematical principles, we should avoid their inflexible application.

The true practice and utility of aesthetic dentistry corrects existing defects while blending functional needs. This ensures a personal, balanced and natural result, which is in harmony with the patient’s entire countenance. Aesthetic dentistry must be reclaimed from its association with cosmetics. Cosmetic dentistry merely covers up defects without integrating functional needs or considering the patient’s countenance. Likewise our artistic skills as aesthetic practitioners need to be reclaimed from overuse of standardized indirect solutions with an attendant loss of aesthetic accountability.

Our personal interaction with and knowledge of the patient can never be fully transferred or delegated to the technician. Simple and elegant solutions should be used whenever possible to provide harmonious and personalized results.

Built on functional prevention and treatment, a truly aesthetic approach capitalizes on that which is natural and individual. Unity provides continuity, while variety captures our attention. Unity and variety work synergistically to create beauty.4 Unity and variety are the essential ingredients of a smile design.5 What is essential to the practitioner is artistic intuition. Intuition allows appropriate variations from the ideal to create a pleasing natural smile. Read wrote, “The appeal of art is not to conscious perception, but to intuitive apprehension. A work of art is not present in thought, but feeling.

It is a symbol rather than a direct statement of truth”.6 Only with this in mind can the full effect and synergy of variety within unity be allowed to play out.

PRACTICAL APPLICATION

Significant progress has been made in the provision of direct restorative materials, yet they demand high proficiency in a stratified layering technique, a feel for composition and an in-depth knowledge of color and light. Attention to detail in the modification and correction of existing teeth requires the synergy of a harmonious integration of smile line placement, axial inclination and medial tipping. Embrasure gradation and regressive proportion, connector zones and gingival contour being equally important.

Knowledge of color and light requires an understanding of basic hue, value and chroma; reflectance and refraction; the different aspects of transparency, translucency and opacity including fluorescence, opalescence and iridescence.7 Detailed attention to final texture, luster and shine complete the skill set. This can ensure harmonious integration of one tooth by simple correction of a single characteristic. It is possible to create an organic and integrated unity in an entire smile and countenance with the balanced re-integration of just one or two teeth.

Indirect restorations, when called for, when used judiciously, and when created in cooperation with a skilled and knowledgeable technician, are nevertheless more invasive and require extraordinary communication. Indirect materials, which have significantly improved as well, still provide superior color stability and physical durability with greater longevity and superior optical and aesthetic properties.

The restorative dentist needs to consider his or her own clinical and artistic limitations in order to develop realistic expectations, which must meet or exceed the patient’s own ideal expectations. With this insight, the option to refer to another aesthetic practitioner or rely on the skills of a laboratory technician can be mutually agreed upon. Likewise, if physical or aesthetic properties of composite resin cannot meet the restorative
expectations in appearance or longevity for the patient, an indirect approach of ceramic restorations must be considered.

PATIENT INTERVIEW

Through the patient interview process the dentist must develop a complete understanding of the patient’s aesthetic expectations. As the distinction between mandatory and elective dentistry becomes more clearly defined, patients are expecting to have more say in the decisions regarding their aesthetic care.8

The primary objective during the patient interview process is to actively listen to the patient’s desire before educating the individual further on treatment options. Effective communication and education during the interview process often precipitate a shift in the patient’s perceptions and even expectations. Interpreting the needs and desires of your patient requires time and perseverance. This enduring process may become quite arduous especially when the patient’s initial inclination is toward an inappropriate appearance or shade.

Knowledge of the patient’s desire is the starting point from which you can guide and direct your patients to an understanding of what displeases them about their smile as well as a full comprehension of aesthetic harmony. An important factor is the patient’s actual level of aesthetic awareness and concern, or what the patient is consciously presenting (that is a specific single defect or overall aspect).

Aesthetic awareness has as much to do with perceived inadequacy as it does with desired expectation. This is based solely on the patient’s own notion of what would be a pleasing end result. Patients with a low aesthetic awareness are more concerned with defects of function. On the other hand, patients with an average awareness are concerned with correction of a defect to blend harmoniously with the patient’s countenance.

A high aesthetic awareness tends to carry an expectation of significant overall improvement and may sometimes be unrealistic in expectation. The patient is largely unaware of how much a subtle alteration in smile design can affect aspects of countenance. The assessment of the patient’s level of aesthetic awareness is the foundation on which to build successful treatment.

Understanding the patient’s self image both negative and positive is pivotal for case acceptance and eventual success of the aesthetic case. Communication, both verbal and visual, generates willingness on the part of patients to take a more active role in their treatment. Educated patients are compliant patients who take mutual responsibility in their care. The ideal patient is one who is educated, engaged and actively participates in their diagnosis and treatment.

AESTHETIC EXAM

Through a comprehensive exam, an integration of functional compatibility with the patient’s aesthetic expectation is determined. A total understanding of the patient’s clinical/structural needs is achieved by means of a thorough diagnosis. Diagnostic modalities should include a complete set of x-rays, intra/ extra-oral photographs, face bow mounted diagnostic models and functional wax-ups based on aesthetic expectations. An aesthetic case should initially be treatment planned without bias to a direct or indirect approach. Diagnostic models (and provisionals) should agree with the patient’s aesthetic vision and provide a template for checking functional and aesthetic requirements throughout.

TREATMENT COORDINATION

Through a treatment coordination appointment, viable aesthetic treatment options are discussed with regard to functional considerations. Communication is fundamental for success. One important aspect of providing aesthetic dentistry is ensuring that the patient is as well informed as possible about treatment options and their outcomes. It is especially helpful in order to facilitate universal understanding to include any significant others at the treatment coordination appointment. This may include a spouse, parent or anyone who may be involved in decision-making or in the financial planning process.

Experience has shown that in most cases, patient dissatisfaction is the result of miscommunication or misunderstanding, not error of treatment. A successful result is assured if at each stage –diagnosis, treatment planning and provisionalization–agreement between dentist and patient is aligned with the functional requirements and aesthetic goals of the case.

The following case studies are intended to illustrate these theories and procedures in practice.

Case 1

A 44-year old male with an average level of aesthetic awareness presented with his chief concern being tooth number 9. A multi-surface composite resin had been placed several years prior. Most likely this tooth had originally been restored with hybrid composite. Through mechanical and chemical attrition a loss of surface “architexture” (texture/luster) had occurred (Case 1, Fig. 1).

Form is the primary determinant of aesthetics. In this case, the primary determinant of aesthetics had been lost or possibly never met. Facial planes, symmetry of incisal width and graduated/symmetrical incisal embrasure spaces all must be evaluated and produced in the final restoration. The patient had recently undergone a number of cosmetic consultations. In order to produce harmony, all the cosmetic treatment plans incorporated an indirect approach utilizing adjacent virgin teeth.

The direct final restoration was achieved with 3 shades/2 opacities of the new generation nano-composite Filtek(tm) Supreme Plus by 3M Espe(tm). This nano-composite is known for its color stability and its retention of polish. Having excellent physical properties makes it useful for posterior as well as anterior restorations. The patient’s expectations were exceeded by this minimally invasive approach. A conservative multi-surface direct composite restoration on tooth number 9 was able to reintegrate harmony in the entire smile and patient’s countenance (Case 1, Fig. 2).

Case 2

A 19-year old female presented with tooth number 9 restored with porcelain fused to metal crown (Case 2, Fig. 1). A dental history revealed that while her orthodontic brackets were being removed, enamel sloughed from the facial of tooth number 9. On three subsequent appointments, the general dentist completed a direct composite restoration on the facial of number 9, which did not meet the patient’s acceptance. Discouraged, the dentist tried to pass aesthetic accountability onto the skills of his lab technician. During the interview process, the patient’s primary concern was not just with tooth number 9. She was concerned with the apparent diastema as well as an irregular incisal edge (Case 2, Fig. 2). With a high level of aesthetic awareness, her primary goal was to achieve a brighter, fuller, more noticeable (cosmetic) smile. After the placement of five laminate veneers and the passage of a few weeks in order to allow moisture to imbibe into the ceramic restorations, a porcelain laminate crown was fabricated to match. A uniform natural transition from cuspid to bicuspid was achieved, allowing for a more conservative six-unit case.

Case 3

A 42-year-old female presented with a chief concern of generalized moderate fluorosis (Case 3, Fig. 1). She had a higher than normal level of aesthetic awareness. Her primary goal was to achieve a brighter, more full smile. She had tried several in-office and home tooth whitening systems, without satisfaction. A natural uniform appearance was her primary goal. Since the patient routinely saw herself speaking on television, she understood that, in general, we expose our upper teeth while smiling and our lower teeth while conversing.

The colors of the mandibular incisors, as well as the chipping of the incisal edges were also of concern. The aesthetic surface of the maxillary incisors is the facial plane. The incisal edge of the mandibular incisors is the aesthetic surface. In order to develop harmony within countenance, an 18-unit maxillary/ mandibular indirect feldspathic veneer approach
was chosen (Case 3, Fig. 3).

The feldspathic technique was chosen here as it provides the lab technician with more control in masking underlying color, compared to a pressed ceramic technique. Ten upper units opposing eight lower units were completed in three treatment phases. This involved first six upper anterior veneers, then six lower anterior veneers and finally the six bicuspids for an exceptional match after moisture imbibition (Case 3, Fig. 4).

Case 4

A 28-year old female, with an average level of aesthetic awareness, presented with tooth number 9 provisionalized with a pre-formed acrylic temporary crown (Case 4, Fig. 1). The treatment was initiated after trauma caused a moderate class IV fracture of the mesio-incisal line angles. She voiced dissatisfaction with the temporary’s aesthetic appearance, as the laboratory was in the process of fabricating a third crown.

The restorative dentist at the most recent appointment had discussed the possible need to crown number 8 to create enough symmetry and harmony to meet her expectations. The patient’s goal was to incorporate the most conservative approach that would restore her original natural smile. A new preparation was completed utilizing a deep modified shoulder preparation at the gingival crest. A new provisional was fabricated from a diagnostic wax-up, cemented and custom stained to match the adjacent dentition (Case 4, Figs. 2 & 3). With an aesthetic provisional that was representative of the final restoration in form and color, the patient left once again confident in her smile. A single-unit porcelain fused to metal restoration was completed which exceeded the mutual expectations created at the provisional stage. The small class IV incisal fracture on the mesial of number 9 was completed at a later date with a direct composite restoration.

Case 5

A 27-year old female presented with four multiple surface direct composite restorations on all four maxillary incisors (Case 5, Figs. 1 & 2). She originally presented with the desire for indirect veneer restorations. Clinical examination revealed wear on the lingual surface of all maxillary incisors. Minimal long centric, along with the numerous Class III and IV restorations determined an indirect restorative approach would require full coverage and be difficult. During the treatment coordination appointment, the patient considering her age and amount of missing tooth structure realized full coverage restorations would eventually be needed, chose the less wanted but more conservative direct restorative approach.

Four multiple surface direct composite restorations were completed utilizing Vit-l-escence(tm) micro-hybrid composite by Ultradent. Vit-l-escence(tm), with its natural high value and characterized incisal shades, was chosen for its ability to match the optical effects of the adjacent tooth structure.

This article may be perceived as a polemic, and in many ways it is intended as such. It is, in this author’s view, imperative that we as practitioners return to an adherence to some time honored principles of dentistry. We live and work in an era where the rationale “First do no harm” collides head on with current practice management theories and marketing strategies that encourage selling cookie cutter “aesthetics” to the extent that the patient can be persuaded into acceptance.

As we surrender the ultimate aesthetic of the natural and individual smile in a harmonious and balanced countenance for what appears too perfect and ultimately resonates as artificial, we see manufactured more and more what used to be pejoratively called a “Denture Look”.

Although there is need for the full smile makeover, there is also much opportunity for the makeover of one single line angle, incisal edge or any of the myriad other options at our disposal. Whether you call it conservative or simply professionally responsible, when we can work with these principles in mind, the result is harmony and balance, variety within unity, in our own practices and lives.

Dr. Arne maintains a highly productive practice emphasizing reconstructive and aesthetic dentistry with a focus on customer service. He lectures nationally on topics of, adhesive and cosmetic dentistry, comprehensive dentistry and occlusion, implantology and dental materials.

*All indirect cases fashioned by ceramist Olivier Tric, 186 N. York Road, Elmhurst, IL 60126 USA

Oral Health welcomes this original article.

REFERENCES

1.Julia E. Diggins, String, Straightedge, and Shadow Viking Press, New York , 1965.

2.Lombardi RE. The Principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973; 29:358-382.

3.Mahshid M, Khoshvaghti A, Varshosaz M, Vallaei N. Evaluation of “Golden Proportion” in Individuals with an Esthetic Smile. J Esthetic Restor Dent 16:185-193, 2004.

4.Ocvirk OC, Stinson RE, Wigg PR, Bone RO; Art Fundamentals: Theory and Practice, edn 6. Dubuque: Wm C Brown; 1990

5.Golub J: Unity and variety:essentialingredients of a smile design. Curr Opin Cosmetic Dent 1994, 2:1-5.

6.Read H: The Anatomy of Art; an introduction to the Problems of Art and Aesthetics. New York; Dodd, Mead, & Co.; 1932.

7.Watkins, N, and Bonnard, P. Bonnard, Colour and Light. London: Tate Gallery, 1998.

8.Goldstein RE,Lancaster SJ. Survey of patient attitudes toward current esthetic procedures. JProsthet Dent 1984;52:775-80.


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