look at aesthetics - amazon s3 1 a look at the principles of dental aesthetics masters in advanced...
TRANSCRIPT
10/10/2014
1
A look at the principles of dental aesthetics
Masters in
Advanced General Dental Practice
Qualtrough AJE, Burke FJT.
A look at dental esthetics. Quintessence Int.1994:25:7-14.
Dental Aesthetics
• Tooth form
• Tooth preparation
• Masculinity/femininity
• Tooth size
• Tooth colour
Length to width ratios Width/Length Ratio?
0.58 0.77 1.0 0.54 0.66
Closest to the
research findings!
Length to width ratios:
There appears to be
wide variability Deficiencies in tooth form
10/10/2014
2
Crown lengthening surgery
needed to achieve
optimum
length/width ratio
Too square
Too long
Just ghastly!
?
Cleft lip & palate
cases
10/10/2014
3
Improvements in tooth form Minimal preparation with resin
10/10/2014
4
21 years
..always
remember
to polish the
interproximal
of
the first one
before
starting
the second!!
Burke and Hussey, Br Dent.J.2003
10/10/2014
5
To “lateralise”or not to “lateralise”?
Missing laterals occur in 1-2% of the population
10/10/2014
6
Decision to open the space or
“lateralise” depends on: Colour, shape and size of canine (?? Sex
of patient)
Patient’s lip support
Smile line
Contra-lateral tooth
Patient’s expectations, requirements & motivation
Patient’s age
Opening the space
Calculate space requirements using
proportions given in Part1
Use a diagnostic wax up
Space may be affected by the choice of
final restoration:
Partial denture
Resin-retained bridgework
Implant
Autotransplantation of premolar
Closing the space
Need to know how to camouflage canines
as laterals
Carefully consider gingival margins
Consider bleaching of canines
Consider functional occlusal relationships
Geometric Theory: Three Forms
of Teeth
• Ovoid
• Tapering
• Square
Dental Aesthetics
• Tooth form
10/10/2014
7
Dental Aesthetics
• Tooth form
• Tooth preparation
Resin cement
will avoid this
Use all-ceramic to avoid need for
subgingival placement of margins
10/10/2014
8
Equigingival margins are OK with zirconia based (Lava) crowns
Dental Aesthetics
• Tooth form
• Tooth preparation
• Masculinity/femininity
• Tooth size
• Tooth colour
10/10/2014
9
Dental Aesthetics
• Tooth form
• Tooth preparation
• Masculinity/femininity
• Tooth size
• Tooth colour
Average exposure for
maxillary central incisor
• 1.91mm for males
• 3.00mm for females
Rufenacht, 1990
Dental Aesthetics
• Tooth form
• Tooth preparation
• Masculinity/femininity
• Tooth size
• Tooth colour
10/10/2014
10
1974
Today:all-ceramic looks better!
10/10/2014
11
Vita 3D Master
metal-ceramic
vs
all-ceramic
Colour matching • Prophy tooth
• Moisten shade guide
• Vary the lighting
• Involve dental nurse and patient
• (For composites) test with cured material without etchant
10/10/2014
12
Are
shade
matching
devices
of value?
Shade change can be
accomplished by simple
procedures
Composite restorations
almost always
need regular finishing
and polishing
Patients must
be warned
that they will
be expected
to pay for this
normal
maintenance
Patient
desire
for aesthetic
restorations
is high
10/10/2014
13
SUMMARY
Shade change can be
accomplished by simple
procedures
!!!!!!!!!
Sometimes more
interventionist
procedures are
needed
Root colour
10/10/2014
14
Root colour
Metal posts corrode, causing root
darkening
Metal posts disrupt the optimum optical
characteristics of the tooth root
Metal posts can show through the tooth
root if the post hole preparation leaves
only a thin rim of tooth tissue
…the answer
Dental Aesthetics
• Tooth form
• Tooth preparation
• Masculinity/femininity
• Tooth size
• Tooth colour
• Tooth position
Tooth position
Good liaison between the restorative dentist and his/her Orthodontist is often central to
the achievement of a good aesthetic result
10/10/2014
15
Ideal tooth alignment
Dental Aesthetics
• Tooth visibility
Tooth Visibility
• Muscle tone
• Skeletal peculiarities
• Tooth length
• Tooth shape
• Tooth position
Visibility of upper teeth on
smiling Ali Fayyad et al., Quint.Int.1995
Gingival margin of 68% of canines did
not show
Gingival margin of 44% of lateral
incisors did not show
Gingival margin of 58% of central
incisors did not show
No statistical difference between men
and women
10/10/2014
16
Visibility of upper teeth on smiling Even if crown margins were not visible on
smiling, a survey of 383 patients has shown
that 15% of men and 11% of women would
object if their crown margins were
supragingival
Watson & Crispin, J.Pros.Dent.1981
Tooth visibility:
Perceived excellence
in dental aesthetics There isn’t much science in this!
The buccal
corridor
Dental Aesthetics
• Tooth visibility
• Symmetry
Symmetry
Horizontal
• Similar elements
from left to right in
a regular sequence
Radiating
• Extends from a
central point with
left and right sides
as mirror images
10/10/2014
17
Symmetry
Dental Aesthetics
• Tooth visibility
• Symmetry
• Dental midline
• Gingival aesthetics
Dental midline Patients views may be
different from ours! Dental Aesthetics
• Tooth visibility
• Symmetry
• Dental midline
• Gingival aesthetics
Gingival health in adhesive
restorations
10/10/2014
18
What is good
aesthetics?
Good aesthetics
means different things
to different people!
10/10/2014
19
Sadly, some patients
choose intervention!
10/10/2014
20
This is the era of
dental aesthetics?
Good dental appearance is now in the media spotlight
Increasing emphasis on dental aesthetics
10/10/2014
21
There are a wide
range of aesthetic
techniques at our
disposal
Aesthetic Techniques Enamel microabrasion
Bleaching
Direct-placement composite
Porcelain laminate veneers
Dentine-bonded crowns
(Crowns & bridges)
All-ceramic/Y-ZTP crowns & bridges
Enamel
Microabrasion
10/10/2014
22
Internal Bleaching
(Walking Bleach)
Peroxide + Perborate
Direct Composite
10/10/2014
23
Colour and composite
The more colours, the more beautiful the final result?
Get to know a small number of colours rather than 31
A colours are best known by clinicians and correspond better with Vita shades than B, C or D.
Is the Vita shade guide OK for composite?
The only certain way is to try on
and cure the composite on the tooth
10/10/2014
24
Treatment? 21 year old female, student
Worried about speckled hypoplasia
Caries free mouth,
excellent periodontal condition
OPTIONS:
No treatment
Porcelain laminate veneers
Any others?
3M ESPE Filtek Supreme XTE: Shade AWB
10/10/2014
25
Non-destructive dentistry at its best?
No chance of pulp death Porcelain
Laminate Veneers
10/10/2014
26
Dentine Bonded
Crowns
All-ceramic
crowns & bridges
N.Tulloch, Alness
There are strong
positive indications for
using aesthetic
techniques which are
nothing to do with
aesthetics P.Hunt, 1987
10/10/2014
27
Treatment combinations
often needed for improving
dental aesthetics Direct-placement composite
Crowns/veneers
Crown lengthening surgery
Orthodontics
Smile aesthetics (from an
orthodontic viewpoint) Appropriate show of gingivae at rest and
full smile
At least 1st premolar to 1st premolar visible
Upper incisors do not touch lower lip
Upper incisor edges are parallel to lower
lip (smile arc)
Simply having straight teeth does not
necessarily guarantee a great smile
Summary
A check list for aesthetic
treatment planning
•Gingival health, level & contour
•Tooth contour
•Tooth axis
•Level of interdental contact
•Relative tooth dimensions
•Surface texture
•Colour
•Incisal edge configuration
•Lower lipline
•Smile symmetry
Can a smile
analysis form
help?
10/10/2014
28
The ethics of aesthetic dentistry
The wages of spin: Failed restorations
Unhappy patients
best treatment is…….
simplest treatment which
will adequately meet the
patient’s needs
It’s survival of teeth
rather than survival of
restorations that is important
Understand:
Yourself!
The patient (why cosmetic dentistry and
why now?)
The problem
The technical procedure and the
technician
Understand:
Yourself!
The patient (why cosmetic dentistry, and
why now?)
The problem
The technical procedure and the
technician
AND
Keep meticulous records
Underpromise and overdeliver!
Complex treatment carries risk!
10/10/2014
29
Burke FJT, Kelleher MGD J.Esthet.Restor.Dent.2009:21:143-145 Burke FJT, Kelleher MGD J.Esthet.Restor.Dent.2009:21:143-145
Similar advice from 2000 years ago.
“Do unto others as you would have
them do unto thyself”
The Bible: Matthew chap 7 verse 11
“In everything,
do unto others what you
would have them do to you.”
New International Version,
1980, New York Int. Bible Society
Ethical considerations Orloff J, Winkler D
In the past, it was inconceivable that the
patient might “want” treatment that was not
directly related to a pathological process
or trauma.
This was deemed unethical by many.
Today, things have changed
For better or for worse?
10/10/2014
30
Ethical considerations
Want vs need
Removal of tooth substance for elective
procedure
Clinician should know longevity of
procedure (in their own hands)
Treatment benefit vs negative
consequences
Patient’s informed consent needed
Above all, do no harm
If harm exceeds potential benefit,
the treatment is unethical
It is unethical to………. Exaggerate one’s clinical skills and
education or use unrecognised credentials
Rely on unproven science to promote
treatments
Carry out unnecessary treatment
Expose patients to the unknown risks of
overtreatment
Charge excessive fees
Simonsen RJ. Commerce v care:
Troubling trends in the ethics of esthetic dentistry
Dent.Clin.N.America 2007:51:281-287
A good motto………. An implicit, if not explicit, assumption
accompanying any treatment is that the
benefits of the treatment will, or at least
are likely to, outweigh any negative
consequences of the treatment…. In short,
that treatment is better than no treatment.
Bader JD, Shugars DA. Variation, treatment outcomes
and practice guidelines in dental practice.
J.Dent.Educ.1995:59:61-65.
For consent to be valid, patients need
to be able to understand……….
The details of the procedure (?? Show
models of preparation??)
Alternatives
Risks
Time scale
Costs
ALL spoken in language that
the patient can understand
The more elective the procedure,
the more disclosure is needed
LAW ETHICS
The Law tells
you what you
can’t do,
Ethics
tells you what
you should do!
Contract Law
A failure to deliver the higher
standard or the promised outcome
could be held to be a breach of the
contract
10/10/2014
31
Negligence
To prove negligence, a patient
must demonstrate, on the balance
of probability that:
The dentist had a duty of care to the
patient
There was breach of that duty
Damage flowed from that breach
either directly or indirectly (causation)
Making an aesthetic treatment plan
Discuss wishes & desires of the patient
Identify & recognise aesthetic problems
Assess technical possibilities & risks of different
treatment options
Talk about costs in £s and tooth substance
Assess prognosis and future possibilities
Judge the expected satisfaction on a scale of 0
to 10 (where 10 = excellent aesthetics), and
inform patient
Discuss with patient: Risk vs Gain vs Cost
Use the “daughter” test!
What is dental esthetics? (Classes of 2008, 2009!)
Fusion of art and science
It’s in the eye of the beholder
Cultural & fashion trends come into it
Mathematical symmetry
Concordant with age
Harmony with surroundings
Patient likes appearance as much as the dentist
Healthy appearance
There must be a balance between aesthetic improvement and health
What is dental aesthetics?
(Classes of 2010, 2011)
Not being noticed
Pleasing to the eye
Natural
Reproduction of the optical characteristics of natural teeth
Correct proportion of tooth/teeth
Soft tissues of good appearance
Socially and culturally acceptable
What is dental aesthetics?
(Class of 2012)
Dentistry pleasing to the eye (of the
beholder)
Maximising natural beauty
Overall net improvement in appearance
Aesthetics is the whole appearance
Perhaps driven by the patient, but,
perhaps resisted by the dentist.
What is dental aesthetics?
(Class of 2013)
Things looking “nice”
Improving appearance
Pleasing to the eye (patient’s)
Pleasing to the eye (dentist’s)
Not always driven by the patient
(relatives etc)
10/10/2014
32
What is dental aesthetics?
(Class of 2014) Does the NHS think that good aesthetics is
necessary? And necessary to secure oral health
Difference between patient’s and dentist’s view:
aesthetics is what can be visualised
Better dental aesthetics improves confidence:
dentist also feels good!
Some people are doing aesthetic dentistry
without sorting out underlying pathology
That’s a look at the principles
of dental aesthetics
Qualtrough AJE, Burke FJT.
A look at dental esthetics. Quintessence Int.1994:25:7-14.
Thank you for listening