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Interdisciplinary Management of Anterior Dental Esthetics PDF
Interdisciplinary Management of Anterior Dental Esthetics PDF
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Anterior Dental Esthetics
Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. JADA 2006;137(2):160-9.
Copyright © 2006 American Dental Association. All rights reserved. Reprinted with permission.
Abstract:
Background. Dental esthetics has become a popular topic among all disciplines
in dentistry. When a makeover is planned for the esthetic appearance of a
patient’s teeth, the clinician must have a logical diagnostic approach that
results in the appropriate treatment plan. With some patients, the restorative
dentist cannot accomplish the correction alone but may require the assistance
of other dental disciplines.
Frank M. Spear, DDS, MSD Approach. This article describes an interdisciplinary approach to the diagnosis
Founder and Director and management of anterior dental esthetics. The authors practice different
Seattle Institute for Advanced
Dental Education disciplines in dentistry: restorative care, orthodontics and periodontics. However,
Seattle, Washington for more than 20 years, this team has participated in an interdisciplinary dental
Affiliate Assistant Professor study group that focuses on a wide variety of dental problems. One such area has
University of Washington
School of Dentistry been the analysis of anterior dental esthetic problems requiring interdisciplinary
Seattle, Washington correction. This article will describe a unique approach to interdisciplinary
Private Practice dental diagnosis, beginning with esthetics but encompassing structure, function
Seattle, Washington
and biology to achieve an optimal result.
Vincent G. Kokich, DDS, MSD
Professor
Department of Orthodontics Clinical Implications. If a clinician uses an esthetically based approach to the
School of Dentistry diagnosis of anterior dental problems, then the outcome of the esthetic treatment
University of Washington
Seattle, Washington
plan will be enhanced without sacrificing the structural, functional and biological
aspects of the patient’s dentition.
David P. Mathews, DDS
Affiliate Assistant Professor
Department of Periodontics Key Words. Interdisciplinary dentistry; anterior dental esthetics; crown length;
School of Dentistry
University of Washington
anterior tooth wear; gingival levels; crown lengthening; orthodontic intrusion;
Seattle, Washington width-to-length ratio; resting lip level; diagnostic wax-up.
Learning Objectives
I n the past 25 years, the focus in den-
tistry has changed gradually. Years
ago, dentists were in the repair busi-
the value of teeth in Western society
also has changed. Yes, the public still
regards teeth as an important part of
After reading this article, the
ness. Routine dental treatment involved chewing, but today the focus of many
reader should be able to:
excavating dental caries and filling the adults has shifted toward esthetics
• explain the treatment planning enamel and dentinal defects with amal- (“How can my teeth be made to look
sequencing concept of beginning gam. In larger holes, more durable better?”). Therefore, the formerly inde-
with esthetics and working restorations may have been necessary, pendent disciplines of orthodontics,
toward biology. but the focus was the same: repair the periodontics, restorative dentistry and
• describe the steps to integrating effects of dental caries. However, with maxillofacial surgery often must join
function and esthetics when the advent of fluorides and sealants, as forces to satisfy the public’s desire to
assessment of esthetics is well as a better understanding of the look better.
accomplished first in the role of bacteria in causing both caries This trend toward a heightened
treatment planning process. and periodontal disease, the needs of awareness of esthetics has challenged
• discuss how the decisions made the dental patient have changed gradu- dentistry to look at dental esthetics in a
in each individual assessment ally. Many young adults who are prod- more organized and systematic manner,
category impact the eventual ucts of the sealant generation have little so that the health of the patient and his
outcome of the case. or no caries and few existing restora- or her teeth still is the most important
tions. At the same time, our image of underlying objective. But some existing
D E F
G H I
Figure 1 This man was concerned about the esthetic appearance of his maxillary anterior teeth (A). At rest, he showed about 4 millimeters of maxillary
incisal edge (B). In protrusive position, he had more than sufficient incisal length to disclude the posterior teeth (C). Because of a protrusive bruxing habit,
his mandibular incisors were worn and positioned apical to the posterior occlusal plane (D). The gingival margins were located correctly and the preparations
had adequate ferrule (E). Therefore, the maxillary incisors were shortened to facilitate restoration of the mandibular incisors (F) and the maxillary incisors (G).
Because the treatment was planned using esthetic principles, it was possible to improve the esthetic proportions of the teeth (H: before; I: after).
dentitions simply cannot be restored to to provide the reader with a systematic would be addressed to provide a pleas-
a more esthetic appearance without the method of evaluating dentofacial esthet- ing appearance of the teeth.
assistance of several different dental dis- ics in a logical, interdisciplinary manner. However, if the treatment planning
ciplines. Today, every dental practition- sequence proceeds from biology to struc-
er must have a thorough understanding Sequencing the ture to function and finally to esthetics,
of the roles of these various disciplines Planning Process the eventual esthetic outcome may be
in producing an esthetic makeover, Historically, the treatment planning compromised. Therefore, we proceed
with the most conservative and biolog- process in dentistry usually began with in the opposite direction: we start the
ically sound interdisciplinary treatment an assessment of the biology or biolog- treatment planning process with esthet-
plan possible. ical aspects of a patient’s dental prob- ics and proceed to function, structure
We have worked in such an envi- lem. This could include the patient’s and, finally, biology. We do not leave out
ronment for the past 20 years. As susceptibility to caries, periodontal any of the important parameters; we
prosthodontist, orthodontist and perio- health, endodontic needs and general simply sequence the planning process
dontist, we have belonged since 1984 oral health. Once the biological health from a different perspective. We choose
to an interdisciplinary study group was re-established—through caries this sequence because the decisions made
consisting of nine dental specialists and removal, modification of the bone and/ in each category, especially esthetics, will
one general dentist.1 We have met or gingiva, endodontic therapy or directly affect the decisions made in the
monthly since that time to educate one tooth removal—then the restoration of categories that are assessed subsequently.
another about the advances in each of the resulting defects would be based on
our respective areas of dentistry and to structural considerations. If teeth were Beginning With
plan interdisciplinary treatment for to be restored or repositioned, the func- Esthetics in Mind
some of the most challenging and tion of the teeth and condyles would When beginning with esthetics, we
complex dental situations. be of paramount importance in dictat- must begin with an appraisal of the
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One of these interdisciplinary areas ing occlusal form and occlusal relation- position of the maxillary central incisors
is esthetics. The purpose of this article is ships, respectively. Finally, esthetics relative to the upper lip (Figure 1). This
D E F
G H I
J K L
Figure 2 This man had significant wear (A) of his maxillary anterior teeth. His incisal edges were positioned coronal to his upper lip (B) at rest. The max-
illary posterior teeth were restored and not worn (C). To determine the extent of treatment, the desired incisal edge position was estimated on the basis
of the existing posterior occlusal plane (D). The gingival margins were estimated by means of the desired width-to-length proportions of the anterior teeth
(D). Then a diagnostic wax-up on mounted dental casts determined whether the correction could be made without orthodontics or jaw surgery (E,F).
The gingival margins were relocated with osseous surgery (G,H). Postoperatively, there was sufficient ferrule with adequate sulcus depth (I ) to create ante-
rior restorations with proper esthetic form ( J ). The final restoration established an improved occlusion (K) with enhanced anterior esthetics (L). Patient
photograph reproduced with permission of the patient.
If the incisal edge display assessment is made with the patient’s is appropriate. However, in a 60-year-
upper lip at rest. Using a millimeter ruler old, the incisal display could be 1 mm
is inadequate, then a or a periodontal probe, we determine or less. The change in incisal display with
primary objective of the position of the incisal edge of the time probably relates to the resiliency
maxillary central incisor relative to the and tone of the upper lip, which tends
interdisciplinary treatment upper lip. The position of the maxillary to decrease with advancing age.
may be to lengthen the central incisor can be either acceptable If the incisal edge display is inadequate
or unacceptable. An acceptable amount (Figures 2 and 3), then a primary objec-
maxillary incisal edges. of incisal edge display at rest depends on tive of interdisciplinary treatment may
the patient’s age. Previous studies have be to lengthen the maxillary incisal edges.
shown that with advancing age, the This objective could be accomplished
amount of incisal display decreases pro- with restorative dentistry,4 orthodontic
portionally.2,3 For example, in a 30-year- extrusion5 or orthognathic surgery.6-8
old, 3 millimeters of incisal display at rest Choosing the correct procedure will
D E F
G H I
J K L
Figure 3 This man had traumatized his maxillary anterior teeth at a young age (A). These teeth were discolored (B), and the incisal edge was positioned
only one millimeter from the lip at rest (C). The maxillary and mandibular incisors were in an end-to-end occlusal relationship (D), which caused further
wear of the maxillary incisors (E). Orthodontic treatment was necessary to retract the mandibular incisors (F) and to facilitate preparation (G) and provi-
sionalization of the maxillary incisors (H,I ). The final restorations were placed after removal of the orthodontic appliances (J). Pretreatment (K) and post-
treatment (L) photographs show the improvement in the appearance of the patient’s smile. Patient photographs reproduced with permission of the patient.
depend on the patient’s facial propor- deviated to the right or left, studies have Usually the decision
tions, existing crown length and opposing shown that midline deviations of up to
occlusion. If the incisal edge display is 3 or 4 mm are not noticed by lay people [between orthodontics and
excessive (Figure 1), then an objective of if the long axes of the teeth are parallel restorative dentistry] will
treatment could be to move the maxillary with the long axis of the face.14,15 So per-
incisors apically by either equilibration,9 haps the most important relationship depend on whether the
restoration,10 orthodontics11,12 or ortho- to evaluate is the mediolateral inclina- maxillary incisors will
gnathic surgery.13 The decision between tion of the maxillary central incisors.
these disciplines again will depend on Researchers have found that if the inci- require restoration.
the patient’s existing anterior occlusion, sors are inclined by 2 mm to the right or
facial proportions or both. left, lay people regard this discrepancy as
The second aspect of esthetic tooth unesthetic.15,16 A canted midline can be
positioning to be evaluated is the max- corrected with orthodontics17 or restor-
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illary dental midline. If the midline is ative dentistry.18 Usually the decision
D E F
G H I
J K L
Figure 4 This woman had short maxillary incisors (A) and significant lingual erosion of these teeth (B) due to bulimia. The amount of incisal edge visible
at rest was about 2 to 3 millimeters (C). Since the maxillary incisal edge was positioned appropriately relative to the posterior occlusal plane and her upper
lip, tooth length was increased with osseous surgery. A surgical guide with proper tooth proportion (D) allowed the periodontist to establish the desired
bone (E) and gingival levels (F,G). By increasing the crown length, adequate ferrule was available (H) to create esthetically proportional anterior restora-
tions (I ). In spite of significant crown lengthening, the tissue health after restoration was satisfactory, and the gingival margins were located properly (J,K),
which enhanced the patient’s smile.
If teeth are retroclined will depend on whether the maxillary dentists do not use these radiographs.
incisors will require restoration. Another method of assessing the incli-
or proclined, correction nation of the maxillary anterior teeth is
may require either Maxillary incisor inclination to evaluate the labial surface of the
Once we have established the correct existing maxillary central incisors rela-
orthodontics or extensive incisal edge position and midline rela- tive to the patient’s maxillary posterior
restorative dentistry and, tionship of the maxillary incisors, the occlusal plane. Generally, the labial
next step is to evaluate the labiolingual surface of the maxillary central incisors
possibly, endodontics… inclination of the maxillary anterior should be perpendicular to the occlusal
teeth. Are they acceptable, proclined or plane. This relationship permits maxi-
retroclined? When orthodontists eval- mum direct light reflection from the
uate labiolingual inclination, they rely on labial surface of the maxillary central
cephalometric radiographs to determine incisors, which enhances their esthetic
tooth inclination.19 However, general appearance.20 If teeth are retroclined or
D E F
Figure 5 This woman had a cant of the gingival margins of the maxillary anterior teeth (A) owing to a right protrusive bruxing habit that had abraded
and shortened the maxillary right central and lateral incisors and canine (B). The incisal edges of the maxillary anterior teeth were positioned properly
relative to the upper lip and posterior occlusal plane (B). The maxillary right anterior teeth were intruded orthodontically (C) to level the gingival margins
relative to the contralateral teeth. These teeth were provisionalized with composite (D) to stabilize them and complete the orthodontic treatment (E).
Intrusion of the right anterior teeth facilitated the esthetic and functional restoration of the dentition (F).
proclined, correction may require either interpupillary line as a guide in estab- The key to determining
orthodontics or extensive restorative den- lishing the posterior occlusal plane.25
tistry and, possibly, endodontics to estab- the correct gingival
lish a more ideal labiolingual inclination.18 Determining gingival levels levels is to determine
The next step is to evaluate the max- The next step in the process of deter-
illary posterior occlusal plane relative mining the esthetic relationship of the the desired tooth size
to the ideal location of the maxillary maxillary anterior teeth is to establish relative to the projected
incisal edge. The maxillary incisal edge the gingival levels. The gingival levels
will be either level with the posterior should be assessed relative to the pro- incisal edge position.
occlusal plane (Figures 4 and 5), coronal jected incisal edge position. The key to
to the posterior occlusal plane (Figure 1) determining the correct gingival levels is
or apical to the posterior occlusal plane to determine the desired tooth size rela-
(Figures 2 and 3). Correcting the pos- tive to the projected incisal edge posi-
terior occlusal plane position will require tion (Figures 2, 4 and 5). It is important
orthognathic surgery,21,22 restorative to remember that the incisal edge is not
dentistry or both.18 The amount of tooth positioned to create the correct tooth
abrasion, the patient’s vertical facial size relative to the gingival margin levels.
proportions and the position of the Using the gingiva as a reference to posi-
alveolar bone will help determine the tion the incisal edges is risky, because
correct solution of posterior occlusal gingiva can move with eruption or reces-
plane discrepancies. sion. Therefore, the ideal gingival levels
After the position of the maxillary are determined by establishing the correct
central incisal edges have been deter- width-to-length ratio of the maxillary
mined, the incisal edges of the maxil- anterior teeth,26-28 by determining the
lary lateral incisors and canines, as well desired amount of gingival display15
as of the buccal cusps of the maxillary and by establishing symmetry between
premolars and molars, can be estab- right and left sides of the maxillary
lished (Figure 2). The levels of these dental arch.18
teeth generally are determined by their If the existing gingival levels will
esthetic relationship to the lower lip produce a tooth that is too short rela-
when the patient smiles.23,24 If the tive to the projected incisal edge posi-
patient has an asymmetric lower lip, tion, then the gingival margins must be
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then it may be more prudent to use the moved apically. This adjustment can be
1. Historically, the treatment planning process 7. When assessing the papilla levels relative to
assessed the following in which order? the overall crown length of the maxillary
a. function, biology, esthetics, structural central incisors, research has shown that the
b. biology, structural, function, esthetics average ratio is about:
c. structural, function, biology, esthetics a. 30 percent contact and 70 percent papilla.
d. esthetics, biology, function, structural b. 40 percent contact and 60 percent papilla.
c. 50 percent contact and 50 percent papilla.
2. When assessing the position of the maxillary d. 60 percent contact and 40 percent papilla.
central incisor, an acceptable amount of
8. If the level of the mandibular incisal edges
incisal edge display at rest depends on:
relative to the face have excessive display,
a. how high the patient’s lip line is.
which of the following options are possible
b. the patient’s periodontal status.
methods of correcting the problem?
c. the patient’s age.
a. equilibration
d. whether the patient can occlude completely.
b. restoration
c. orthodontic intrusion
3. Studies have shown that midline deviations
d. all of the above
of up to what amount are not noticed by lay
people if the long axes of the teeth are parallel 9. The first step to integrating the esthetic
with the long axis of the face? plan with the functioning occlusion is to
a. 1 or 2 mm evaluate what?
b. 2 or 3 mm a. the density of the bone structure
c. 3 or 4 mm b. the temporomandibular joints and muscles
d. 4 or 5 mm c. the alignment of the jaw
d. the periodontal status of the patient
4. Generally, what surface of the maxillary
10. If leveling of the occlusal planes creates an
central incisors should be perpendicular to
acceptable anterior dental relationship, the
the occlusal plane?
patient’s existing vertical dimension can be
a. occlusal
maintained by leveling only the:
b. lingual
a. mandibular incisors.
c. labial
b. maxillary incisors.
d. facial
c. mandibular bicuspids.
d. maxillary bicuspids.
5. What characteristics will help determine
the correct solution of posterior occlusal
plane discrepancies?
a. the amount of tooth abrasion
b. the patient’s vertical facial proportions
c. the position of the alveolar bone
d. all of the above