Esthetics

1. Esthetics • Harmony of facial structures that we overlook most of the time is worthy of watching

2. Esthetics • Beauty in Dentistry today does not differ very much from art in general. • Any esthetic restoration requires imaginative skills superior clinical talents and the comprehension of all facial relationships that make treatment successful.

3. Esthetic Dentistry • Critical aspects of esthetic dentistry- Proper tooth size, form and color of restorations • Periodontal component must also be addressed for a predictable esthetic outcome

4. Smile • Maxillary central incisors completely displayed • Maximum of 2 mm gingival visible • Gingival level of maxillary centrals should be in line with cuspids and this line is parallel to the interpupillary line • The lateral incisiors would be a little more coronal to this line ( <1mm)

5. The teeth should also be symmetrical with the proximal of the central incisors aligned with the facial midline • The teeth should fit the rule of golden proportion with the incisive edges of maxillary teeth parallel to the lower lip

6. The periodontium • The gingival contour is scalloped • Soft tissue papillae occupy the embrasure spaces

7. Any breach in these basic guidelines- Unacceptable esthetic outcome.

8. Crown lengthening • Restorative • Non -restorative Subgingival fracture Subgingival caries Endo/post perforation Inadequate axial height for retention Unequal gingival levels Esthetically short crowns due to wear Altered passive eruption

9. In anterior esthetic cases surgical modification of the dentogingival complex is often needed to improve the alignment of the gingival crest and provide the framework to achieve esthetic success.

10. Biologic width • Mean sulcus depth: 0.69mm • Epithelial attachment: 0.97mm • Connective tissue: 1.07mm • Total dimension is 2.73mm • Based on these dimensions several authors have suggested that 3mm of supracrestal tooth structure be obtained during surgical crown lengthening

11. Violation of the biologic width: Restoration margins on teeth Nos. 8 and 9 were placed 4 mm subgingivally in close proximity to the alveolar bone. Notice the inflammatory changes on the marginal gingiva.

12. Case shown in Figure 2 following elevation of a buccal flap. Notice the minimum distance between the restoration margin and the crest of the alveolar bone.

13. One area of specific concern is excessively short teeth where the lack of adequate teeth display and excessive gingival display require clinical crown lengthening.

14. Anatomical basis for a gummy smile • Delayed passive eruption: • Tooth eruption consists of an active phase and a passive phase. • Active eruption is the movement of teeth in an occlusal direction. • Passive eruption is the exposure of teeth by apical migration of gingiva.

15. Delayed passive eruption • Or altered passive eruption is the failure of the gingival tissue to adequately recede to the proper level relative to the Cementoenamel junction • Short crowns and gingival excess • occurs in 12.1% of the population. • 7% in men and 14% in women.

16. Treatment options • Gummy smile can only be resolved with esthetic crown lengthening. • Veneers only may not be the answer

17. Classification • For differential diagnosis and appropriate treatment: • Attached gingiva-crown relationship: • Type 1: The gingival margin is incisive to the CEJ with a wider zone of keratinized gingiva In this type crown lengthening can be achieve by gingivectomy as long as 3-5mm of attached gingiva are preserved.

18. Type II : The gingival margin is incisive to the CEJ, but the width of the attached gingiva is normal. In this situation, the attached gingiva must be preserved, and crown lengthening is achieved by apically positioning the gingiva.

19. Alveolar crest-CEJ relationship. • Subgroup A: The underlying alveolar crest is located 1.5 to 2.0mm apical to the CEJ. In this case esthetic crown lengthening can be performed without osseous resection. • Subgroup B: The Alveolar crest is at the CEJ. For this group, esthetic crown lengthening requires 2-3mm of osseous resection to establish the ideal biologic width.

20. Treatment planning • Understand patient expectations • Diagnostic wax up • Temporary restorations • Referral

21. Average length and width of Maxillary anterior teeth Central Incisors Mean width: 8.6mm Length: 10.2mm Lateral Incisors Mean width : 6.6mm Length: 8.7mm Canines Mean width: 7.6mm Length: 10.0mm

22. Proportion guages Diagram of T-Bar Proportion Gauge tip (ie, Chu’s Aesthetic Gauges, Hu-Friedy Inc, Chicago, IL). Once the desired tooth dimensions are determined, the adjunctive periodontal procedure can be performed whether treatment entails crown lengthening or coverage The Proportion Gauge tip is designed for simultaneous width and length measurements of the maxillary anterior dentition. The average central incisor measures 8.5 mm in width by 11 mm in length (see red markings)

23. Why not lasers??? • It is important for the restorative dentist to recognize that coronally positioned gingival crest is sometimes associated with a similarly positioned alveolar crest • Also if the attached gingiva is minimal ( 2-3mm) a gingivectomy can cause a mucogingival defect • Therefore it is critical that the dentist properly diagnose the anatomical relationship that caused the gummy smileand select the appropriate treatment.

24. Healing process • Important aspect: The length of time between the surgery and preparation/impression • Initial healing may take upto 2-3 months • In situations where complete healing is not permitted and veneers are placed too early, violation of the biological width is possible potentially resulting in chronically inflamed gingival tissue.