Normal Proportions of the Face

• The normal human face can be divided into thirds

• Average eye distance is 28.32mm

• Usually people show 2-3mm of tooth with relaxed lips

Julie Beegan Source: http://www.ppsca.com/dentface.html

Normal Gingival Contours

• Described as being either thin and scalloped, or thick and flatter in contour. The contour of the gingiva depends on the contour of the cementoenamel junction of the teeth, the amount of embrasure space, and the nature of the contact between teeth. The gingiva appears prominent over the tooth root and may have a slightly concave appearance in the interproximal area.

Serio F.G, Hawley C.E, Manual of Clinical Periodontics A.Tujios

Smile Line AnalysisJessicaL. Rainey

• Subjective- patient’s perception of their smile• Objective- measurements to quantify data

– tooth shade– distribution of color– defects and discoloration of the tooth structure– crowding, spacing– visible fillings or crowns– shape and size of teeth– amount of gum tissue shown when smiling

• Prior to a smile analysis, a thorough exam, including appropriate radiographs, should be completed to ensure that more pressing concerns such as decay and infection are not present. Depending upon the results of your smile analysis, you may wish to take impressions of the teeth to create study models. These models can be used to help plan treatment and create a diagnostic wax-up of possible treatment results.

Smile Analysis con’t

Lip formation• the lip may come up high and reveal some of your gum tissue• lower lip may be either rounded or straight across  What to aim for:

No excessive gums showing. The lower lip should be rounded. How to get it: The height of the gum can be altered.  

Edge/line of teeth• Edge or line of the teeth goes straight across or is curved.• The line of the upper teeth should mimic the line of the lower lip.  • Teeth can be reshaped to give flattering lines and edges.  

Color of teeth• Whiter teeth are brighter and more youthful looking.  Broken Teeth• Bonding, crowns and veneers can fix decaying and broken teeth.

Short Lip vs. Hyperactive Lip

•Average length of the maxillary lip (measured in repose from subnasale to its inferior border)

20-22mm in young adult female

22-24mm in young adult male

•Short lip = maxillary lip fails to achieve the prescribed norms

Short lip vs. Hyperactive lip• Hyperactive lip –

excessive gingival display when the face height, gingival levels, lip length, and length of the central incisors are all within acceptable limits– Average translate

approximately 6-8mm from repose to full smile

– Hyperactive lip translates 1.5-2x more

Robbins JW. Differential diagnosis and treatment of excess gingival display. Pract Periodont Aesthet Dent 1999; 11(2): 265-272.

Diagnostic Wax-Up

Steps:

1. Patient profile (age, sex, oral hygiene status, smoker, systemic, etc.)

2. Smile analysis with clinical photos

3. Determine biologic width as well as clinical attachment.

4. Study model fabrication

5. Model surgery (determine loss of supporting structures and incorporate into model)

Gyula Takacs

Diagnostic Wax-Up

7. Wax to new restorative margin with the lower incisors being 1mm lingual to and 1mm inferior to the upper incisors.

8. Make a surgical template to aide in the surgery.

Gyula Takacs

Diagnostic Wax-Up

References:Shillingburg, Herbert. Fundamentals of Fixed Prosthodontics, 3rd Edittion. Quintessence, 1996.

Scutella F, Ladi L, Stellino G, and Morgano S (1999)Surgical template for crown lengthening: Aclinical report.

Journal of Prosthetic Dentistry. 82(3): 253- 256.

Columbia Dental Review 2000: 5:21-24..

Surgical Crown Lengthening: A 12-Month Clinical Wound Healing Study. J. of Periodontology. July 2001 (Volume 72, No. 7) 

J Can Dent Assoc 2001; 67(10):600-3 

Gyula Takacs

Evaluation of Patient Desire

Evaluating the patient’s desire can only be achieved by understanding the components which contribute to the esthetics of the smile. These components include:

facial - facial features (nasolabial groove, etc), tooth visibility, lip line, smile line, upper lip curvature, symmetry, negative spacedental - midline, alignment, arrangement, gradation, shape, contacts/embrasuresgingival - morphology, contour, healthphysical - illusion effects of artificial teeth

Only with a thorough background in the rules of esthetics can a detailed evaluation of what the patient desires be achieved. This is critical because the patient may be unable to accurately describe their own desire. Of course, take pre-op photographs, formulate a treatment plan and prepare to moderate the patient’s expectations.

Michael Kim Ref: CR Rufenacht. Fundamentals of Esthetics. Quintessence. 1990. p.67-132.

Altered Passive Eruption: Definition

• Altered Passive Eruption is an aberration in normal development where a large portion of the anatomic crown remains covered by the gingiva

This complicates dentofacial harmony for two dominant reasons:1. Usually results in a square tooth shape2. The excess soft tissue displayed makes a potentially

medium lipline into a high lipline

Garber, D. A., Salama, M.A. The Aesthetic Smile: Diagnosis and Treatment. Periodontology 2000. Vol. 11. 1996. 18-28. Jonathan Chiang

Black Triangles

• Defintion: “Black triangles” occur when the interdental papilla fails to fill completely the interdental space.

• Diagnosis: May exist due to:

Gingival recession

Highly tapered triangular tooth form

Previous periodontal surgery

Black Triangles

• Treatment options:OrthodonticsRestorative recontouring (crowns, veneers)Periodontal surgery- Free gingival graft

Source• http://www.cda.org/member/pubs/journal/jour1102/sheets.

htmNick Ferri