Esthetics

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Esthetics

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

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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.

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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

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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 ( lt1mm)

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• 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

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The periodontium

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

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

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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
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• 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.

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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

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

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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.

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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.

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Treatment options

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

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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.

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• 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.

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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.

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Treatment planning

• Understand patient expectations
• Diagnostic wax up
• Temporary restorations
• Referral

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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
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Proportion guages

• Diagram of T-Bar Proportion Gauge tip (ie, Chus
  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)
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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.

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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.

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