Journal of International Dental And Medical Research ISSN 1309-100X Esthetic Failures in Fixed Partial Dentures

http://www.ektodermaldisplazi.com/journal.htm Veu N.V.Madhav

ESTHETIC FAILURES IN FIXED PARTIAL DENTURES

V N V Madhav1*
1. Dr, M.D.S. (Prosthodontics), Reader, Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune, India.

Abstract

Esthetic dentistry encompasses those procedures designed to enhance and improve form and
appearance of the maxillofacial region. Esthetic dentistry procedures are performed on both hard
and soft tissue to correct either subjectively or objectively, patient perceived deformities.
Perceptions of esthetic deformities or needs are highly subjective. In this article an effort has
been made to outline the possible esthetic errors which occur in the absence of careful treatment
planning during the fabrication of fixed partial denture procedure.
(J Int Dent Med Res 2010; 3: (3), pp. 146-153 )

Keywords: Esthetic Failures, Shade Selection, Gingival Esthetics, Esthetic Smile.

Received date: 19 July 2010 Accept date: 21 September 2010

Introduction along with need for dedicated maintenance. The

The surge of interest in the use of tooth-
colored restorative materials and systems in
recent years has been attributed partly to rapid
developments in dental materials science and
also to patient demand and operator interest.
When overall dental appearance is
considered, several factors are of significance,
including tooth color, shape, and position;
restoration quality; and the general arrangement
of the dentition, especially of the anterior teeth.
Each factor may be considered individually, but
all components together act in concert to produce
the final esthetic effect. However, although the
clinician must be mindful of the patient's desires
for a favorable cosmetic result, materials and
techniques must be carefully selected, and
restorations should be sufficient to withstand the
forces of occlusion and mastication and provide
long-term function and esthetics1.
The elective nature of esthetic procedures
requires that the patient is thoroughly educated
about possible risks and adverse consequences
*Corresponding author:
Dr. V.N.V.Madhav, M.D.S. (Prosthodontics)
Reader, Department of Prosthodontics,
Bharati Vidyapeeth Dental College and Hospital,
Pune .
E-mail: vnvmadhav@yahoo.co.in
proper selection of treatment occurs through a
comprehensive dialogue between the
Prosthodontist and the patient in which both
subjective and objective evaluations are utilized
to determine appropriateness of treatment and
thus enable the assumption; of reasonable risk /
benefit ratio. The irreversibility of many esthetics
procedures requires that the patient be fully
aware of future additional and / or alternative
treatments if their initial esthetic goals are not
met. In this article an effort has been made to
outline the possible esthetic errors which occur in
the absence of careful treatment planning during
the fabrication of fixed partial denture procedure.
Evolution of Ceramics as an Esthetic
Alternative
The metal-ceramic crown was introduced to the
profession over four decades ago. At the time
there was tremendous excitement generated by
the concept because it theoretically combined the
esthetics of the porcelain jacket crown with the
potential for clinical longevity2.
However, it is likely safe to state that most
clinicians were somewhat disappointed by the
initial clinical results obtained with this treatment
modality. It is highly likely that most early esthetic
failures with metal-ceramic restorations were due
to a combination of errors in tooth preparation,
cervical margin design and soft-tissue
management. Nevertheless, the disappointment
with metal-ceramic restorations was the genesis

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for the development of numerous all-ceramic  Midline error

alternatives to the metal-ceramic restoration. The  Imbalance of directions
past two decades has witnessed the  Artifact error
unprecedented introduction of alternatives to the  Diastema error
metal ceramic crown 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16.
In addition, many different techniques for Factors Affecting Esthetic Failures
fabrication of all-porcelain labial margins have One of the goals of any dental restoration
been developed to improve the inherent esthetic should be patient satisfaction. The restoration
performance of metal-ceramic restorations 17, 18, 19, should fulfill the requirements of correct
20, 21, 22
. In clinical situations with sufficient mastication function, appropriate morphology,
remaining enamel, etched porcelain laminate superficial staining, abrasion and other
veneers may also be considered to restore the characterization. Finally, the shade selected
teeth to both optimum esthetics and function 23, 24, must correspond to the individual, age related
25, 26
. appearance of the patient and should be identical
Thus, the contemporary host of indirect to the remaining natural teeth. Problems that
alternatives for the esthetic restoration of anterior arise during fabrication can be overcome in spite
teeth. It is also clear that ceramic technology has of the difficulty level, which varies from case to
matured to the point that it is possible to mimic case and depends in part on whether the
nature and provide restorations that defy restoration involves a single crown or a fixed
detection to even the trained observer. partial denture. A general requirement for the
success of laboratory work by the dentist (i.e.;
Classification of Esthetic Errors27; proper shade selection, correct tooth preparation
(Richard E. Lombardi; 1974) and final impression).
I. Inharmonious dento-facial ratio
1. Shade disharmony Tooth Shape
2. Compositional incompatibility The facial surface of the tooth is a part of
 Static prosthesis in dynamic mouth tooth form. It is decisive in shaping tooth's
 Inharmonious strength or weakness of appearance, particularly when severe changes
dental composition compared to occur in old age. The incisal edge, which may be
background features. slightly convex in shape initially, changes as well.
a. Weak mouth with strong face. As a consequence of abrasion it may
b. Strong mouth with weak face. eventually become concave. All of these variable
II. Intrinsic dental disharmony characteristics of tooth shape combine to
1. Space allocation errors determine the effect of the tooth in the mouth, to
 Inadequate vertical space allocation a significantly greater degree than does the
 Excessive vertical space allocation shade. The changes in the cervical region,
 Excessive horizontal space allocation through gingival recession for example, also lead
2. Structural line errors to an appearance typical of a certain age. These
 Elevated occlusal plane changes have a more pronounced effect on the
 Occlusal plane drops down posteriorly appearance of the dental arch than on the shade.
 Asymmetrical occlusal plane Because the gingiva usually recedes
3. Unnatural lines inter-proximally as well, it leaves the crown of the
 Reverse smiling line tooth with a more triangular appearance. If these
 Unnatural axial inclination teeth are replaced by a restoration having a
 Cusp less posterior teeth square form, they will appear more unnatural. It
is expected that the form of the clinical crown
 Gradation errors
correspond to the course of the root, which is
 Age-sex personality disharmony
often exposed because of periodontal disease.
4. Single-line errors
 Vertical deviation Surface Structure and
 Horizontal deviation Characterizations
 Line conflict The natural surface detail is most
5. Imbalance extensive in a young tooth. Many fine, detailed

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irregularities occur, particularly on the labial
surface. At the first glance one sees horizontal
depressions. Vertical lines become visible with
more careful observation, so that a pattern of
very fine, slightly displaced rectangles is seen.
The older a tooth becomes, the less
prominent these structure become. Millions of lip
movements in the same direction lead to
formation of large smoothed regions between
which few structured zones are retained. Enamel
tears, abrasions, discoloration, incisal edge
irregularities, bright spots, and band-shaped
shade variations are not the only
characterizations that must be evaluated.
Cervical erosions and fine lines that
separate the clinical crown and the root, which
may result from simple aging or from oral
hygiene procedures, must also be evaluated.
Color
Nature of Color: When we talk about
color, we are making reference to a sensation
which is captured by our eyes. The human eye is
an organ specialized in the reception of images
obtained from an electromagnetic radiation that
we refer to as light, and which actually
corresponds to a narrow segment of the entire
spectrum, situated between the 400 and 800 nm
wavelengths approximately, and which we
perceive as the so-called “colors of the rainbow”.
Radiations below these wavelengths are
not visible to the human eye, and are referred to
as ultraviolet; those which are situated above
these wavelengths are not visible either, and are
referred to as infrared.
There are generally three accepted
dimensions of color:
 Hue, tonality: this indicates the feature which
is normally referred to as color, directly related
to the wavelength of the observed luminous
radiation observed (e.g. red, green, blue,
yellow…).
 Value, luminosity: this expresses the amount
of light that makes up the color under study,
and would be like the black and white image
of the observed object, corresponding to the
tonalities of grey ranging from a maximum
value, white, and a minimum value, black.
 Chroma, saturation: this refers to the amount
of dye that the color contains, the chromatic
brightness that we observe. This dimension
refers to the different dilutions of the base
color we are starting from.
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Esthetic Failures in Fixed Partial Dentures
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To these three dimensions, and within the
field of dentistry, we must add a fourth one which
would include all of the chromatic features that
personalize the tooth apart from its average
color, and which are fundamental for the repro-
duction of the color of a tooth.
Gingival Esthetics
Factors Affecting Gingival Esthetics:
The morphology and dimension of supracrestal
periodontal tissues undoubtedly represent the
most important parameters to be taken into
consideration in designing a fixed prosthesis28.
The Esthetic Width; As the supracrestal
connective tissue attachment is resected during
tooth preparation, so should the esthetic width be
respected when designing the prosthetic
framework, a distinct space is necessary
between the coronal border of the gingiva and
the cervical margin of the framework to provide
adequate room for the application of specific
shoulder porcelain.
The Umbrella Effect; A careful analysis of
clinically relevant optical phenomena should
always include the effect produced by the lips,
particularly the upper lip, because this feature will
significantly influence the interaction of light with
the teeth and their supporting tissues. When the
lips are retracted, the apical extension of the
framework generally will not have a strong impact
on the optical behavior of the crown, because the
light can be directly distributed into the tissues.
When the upper lip is in its normal
position, however, the difference becomes
significant, because direct penetration of light into
the surrounding periodontal tissues is prevented.
In contrast, an adequately reduced framework
does not demonstrate the so-called umbrella
effect.
Esthetic Smile
The smile is expressed by muscular
action around the lips in the inferior third of the
face by a brightening of the eyes. The pleasing
smile is one of our special forms of nonverbal
communication, and it expresses joy.
The elements that effect in an esthetic
smile are;
 The upper lip position
 The upper lip curvature
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 The parallelism of the anterior incisal curve
with the lower lip
 The relationship between the maxillary
anterior teeth
 The number of teeth displayed in a smile
The most attractive smiles have nearly
perfect harmony between the arcs of curvature of
the incisal edges of the maxillary incisor and the
upper border of the lower lip, and the upper lip
can be at the height of the gingival margin of the
maxillary central incisor. It was found that in an
attractive smile, the full shape of the maxillary
anterior teeth was displayed between the upper
and power lip. The upper lip curved upward or
was straight, the maxillary anterior incisal curve
was parallel to the lower lip, and the teeth were
displayed to the first molar.
SHADE SELECTION FAILURES
To date, there is no systematic training on
visual shade determination 29, 30, 31 for dental
technicians or dentists32. Therefore; all attempts
to improve the color communication fail at this
barrier.
The many difficulties associated with
visual shade determination of manufactured or
customized shade tabs for natural teeth are
further complicated by the fact that color
interpretation by the human eye is influenced by
a variety of factors.
Shade selection is an important
procedure to provide patients with an aesthetic
restoration that harmoniously blends to the
patient’s existing dentition. Knowledge of the
scientific basis of color from understanding light
to also interpreting the artistic aspects of shade
selection ensures a successful result. Shade
selection involves the perception of color, which
depends on three entities:
1. Light
2. Object; and
3. Visual detection
The visual system of the eye is only
capable of detecting wavelengths from 380
(violet) to 780nm (red). Isaac Newton showed
that light had no color, as it is only when it
interacts with an object that color is produced.
Light
The color of an object can change
depending on the illuminant, e.g. tungsten light
may cast a yellow color compared to daylight.
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The property of light source to influence color of
objects is called “color rendition”. There are three
main illuminants within any dental practice:
natural, incandescent and fluorescent.
Natural sunlight is itself variable with light
appearing blue at noon when the sun has fewer
atmospheres to penetrate and red/orange during
the morning and evening. Incandescent lighting
is predominantly red/yellow and lacking in blue
while fluorescent lighting is high in blue tones
and low in red. There are special that are
color corrected to emit light with a more uniform
distribution of color that can be utilized. Initial
shade selection should be initially made with be
matched under different lights to avoid
metamerism (the phenomenon that occurs when
shades appear to match under one lighting
condition and not another).
Factors Affecting Light Conditions
 Gingival shade
 Influence of the surroundings
 Type and arrangement of the shade guide
 Position of the shade tab
 Different color perception capacities
 Knowledge about color and its perception
 Experience in shade selection
 Acting mechanism of the eye (simultaneous
contrast, contrast increase)
When determining a color, the human eye
perceives a certain shade; however, under
modified light conditions, the color perception
and the subsequent shade selection can be
completely different. This implies that when
shade guides are used exclusively, the tooth
shade required is always described in an
insufficient manner33-35.
It is important to use auxiliary tools and a
shade indicator that is arranged according to a
logical system oriented by the natural model
Object
Color possesses three dimensions: value,
hue and chroma. A high value object often
reflects most of the light falling on its surface and
appears bright. The converse is true with a dark
object absorbing most of the light and appearing
dull or of low value. Hue is wavelength of light,
and dependent on the spectral reflectance from
an object. Chroma is the concentration of color or
color intensity
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Visual detection
The third part of stimulus for color is the
spectral response of the detector, or eye. The
difficulty of shade selection is that clinicians must
be able to interpret a multi-layered structure of
varying thickness, opacities and optical surface
characteristics. This can affect the way that the
eye perceives color. The basic hue of the tooth is
determined by the color of the underlying dentine,
while value is a quality of the enamel overlay.
Muia in 1993 stated, “The dentine imparts
the entire color. Enamel is like a fiberoptic
structure conducting light through its rods”.
Chroma is the saturation of color in the
dentine, but is influenced by the value and
thickness of the enamel. Teeth are often termed
“polychromatic” and have the variation in hue,
value and chroma within the teeth and give three
dimensional depth and characteristics. A young
dentition is characterized by opaque, high value
enamel, which blocks underlying dentine. As
teeth age, the enamel becomes more translucent
and dull (low value) revealing the underlying
dentine. This layering can make reading of tooth
color difficult since the value of enamel and
surface luster often complicate color evaluation
of the underlying dentine.
Contrast Effect
When a dental restoration is being
fabricated, the surroundings of the teeth,
especially the shade of the gingival tissues, are
decisive for the color integration of the restoration.
With the conventional visual shade determination,
so-called simultaneous contrast effects and
contrast increases occur 36, 37, 38.
To explain briefly: Shade selection is
performed in a reddish environment-skin, lips,
and gingival tissues. This environment, and
especially the reddish-violet color of the gingival
tissues, leads to a marked decrease in the
receptiveness of this area to the color spectrum
The brain replaces the apparent excess of red
with the complementary shades green to yellow.
This leads to a subjectively modified color
perception, which expresses itself in a tendency
toward seemingly objective yellowish shades.
This contrasting effect can be neutralized by the
use of a gingival mask.
Tips to Remember During Shade
Selection Procedure
 Shade selection should be completed before
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preparation as teeth can become dehydrated
and result in higher values.
 Shades should be done when the dental team
is not fatigued as in the end of the day.
 Ensure surgery surroundings are of neutral
color so that there is no color cast onto the
teeth.
 Remove lipstick; ask patients not to wear lurid
clothing or any items that may distract the
attention of the teeth.
 Make sure teeth are clean and unstained
before attempting shade selection.
 Patient should be in an upright position at a
level similar to the operator and the shade
guide should be at arms length. This ensures
that the most color sensitive part of the retina
will be used.
 Observations should be made quickly (5
seconds) to avoid fatiguing the cones of the
eyes. If longer than this, the eye cannot
discriminate and the cones become sensitized
to complement the observed color.
 Blue fatigue can accentuate yellow sensitivity
so dentists can look at a blue object, bib, etc,
while resting the eyes.
 Use color corrected light illumination, which
should be of a diffuse nature.
 Choose basic shade at the middle of the tooth
- using the Vita System 3D-Master technique
of value, chroma then hue. Viewing tabs
through half-closed eyes can decrease ability
to discriminate color but increases the ability
to match value. Look at the other parts of the
teeth, dividing the teeth into nine sections
from apical to incisal and mesial to distal.
 Necks of shade tabs often can be removed as
they have a great deal of colorants that may
introduce errors.
 Examine tooth for translucency and any
characterizations, e.g. craze line,
hyopcalcification, etc.
 Create a shade/chromatic map – divided into
different sections to ensure correct placement
of different effects, characterizations and
shades.
 In case of color blindness, seek the help of the
assistant
 Shade selection is done before tooth
preparation
 Don't dry the tooth while selecting the shade
 Moisten the shade tab
 Canine is the darkest tooth
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 Premolars are of lighter shade than canine
 For premolar select contra-lateral premolar
 When maxillary anteriors are missing, shade
of the mandibular anteriors are considered
 In case of a non-vital tooth, cover it and select
the shade of the adjacent tooth.
 Photograph teeth and tabs using different
lighting conditions to minimize metamerism,
e.g. flash (5500K) and natural daylight
(6500K).
 Photograph teeth at 1:1 ratio for detailed
characterizations.
 Send digitized images and shade map to
ceramist.
Stump shade selection
With the increasing use of all-ceramic
restorations, it is important to communicate the
prepared tooth or “stump” shade to the ceramist
so that they can build the restoration with the
right opacity/translucency. It may be necessary
as in to use a more opaque ceramic to block out
discoloration, e.g. an alumina- or zirconia based
restoration may be a better choice than a glass-
based ceramic like Empress.
Although no single shade guide or
combination of guides includes all of the color
combinations that may be encountered in clinical
practice, a reasonably high level of clinical color
matching has been achieved, which attests to the
artistic skills of many dentists in selecting the
best available shade and determining what color
modifications are necessary to further enhance
the color match.
Instrumental Shade Selection
Given the great subjectivity that
predominates all during the color measurement
process in the clinic, a series of electronic
instruments designed to facilitate and make more
objective the process of color measurement have
recently been appearing on the market. The
practitioner thus needs only to use these devices
in order to be able to indicate the tooth’s color in
a more precise, reliable and repeatable way.
Knowledge of the correct use of the
conventional color measurement systems is
becoming more and more important if we wish to
satisfy present day esthetic demands.
This, together with the gradual entry and
perfection of the electronic color meter systems,
will serve to reduce the possibilities of aesthetic
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failure, and thus increase the quality of
restorations.
Table 1. Commercially Available Digital Shade
Guides.
As a summary reasons for esthetic
failures can be summarized as following.
 Failure to identify patient expectations
regarding esthetics
 Improper shade selection
 Failure to transfer the shade to dental
laboratory
 Excessive metal thickness at incisal and
cervical region
 Thick opaque layer application
 Surface blistering ("chalky" appearance)
 Over glazing or too much smooth surface
 Metal exposure in connector, cervical and
incisal regions
 Dark space in cervical third due to improper
pontic selection (Anteriors)
 Failure to produce incisal and proximal
translucency
 Improper contouring
 Failure to harmonize contra-lateral tooth
morphology
1. Contour
2. Color
3. Position
4. Angulations
 Discoloration of facing
The contemporary restorative dentist has
a host of options with which to help his or her
patients are treated. Many of these options are
considerably less invasive than many of our
conventional restorative therapies. Many patients
present for esthetic restorative treatment, and are
becoming increasingly sophisticated in their
expectations of the final results. Additionally,
manufacturers are bringing a myriad of new
products to the market, often accompanied by a
blizzard of information purported to demonstrate
the benefits and efficacy of these new products.
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Careful evaluation of patient’s expectations and
needs and proper choice of materials and
techniques along with sound knowledge and skill
of the operator can decrease the failures in the
esthetic outcomes in fixed partial dentures.
Conclusions
Today’s dental restoration is consolidated
around three mainstays: the use of non- metallic
materials, such as composite resins and
ceramics; adhesion to dental structures; and the
achievement of a natural cosmetic look. The level
of esthetic requirement and demand by patients
in restorations has risen spectacularly in recent
years, and this has made it necessary for dental
professionals to explore this field in order to
satisfy the existing social demand in this area.
The dental materials that are available
nowadays offer us the possibility of imitating the
tooth’s natural esthetic look, so long as the right
one is chosen for a given situation. The first step
to achieving clinical success in esthetic dentistry
will therefore be to correctly identify the patient’s
needs and to imitate tooth color with the material
that most closely matches, and to communicate
this information to the laboratory if the restoration
is to be carried out there.
Color measurement may seem to be a
minor element within the field of Restorative
Dentistry, but its importance is essential,
although not from the biological point of view. But
given the present day level of esthetic exigency,
a technically correct restoration can be a clinical
failure if it fails to achieve the esthetic integration
the patient nowadays demands.
Declaration of Interest
The authors report no conflict of interest
and the article is not funded or supported by any
research grant.
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