A look at the principles of dental aesthetics. Dental Aesthetics. Deficiencies in tooth form. Length to width ratios

Transcription

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? Closest to the research findings! Length to width ratios: There appears to be wide variability Deficiencies in tooth form 1

2 Too square Crown lengthening surgery needed to achieve optimum length/width ratio Too long? Just ghastly! Cleft lip & palate cases 2

3 Improvements in tooth form Minimal preparation with resin 3

4 21 years..always remember to polish the interproximal of the first one before starting the second!! Burke and Hussey, Br Dent.J

5 To lateralise or not to lateralise? Missing laterals occur in 1-2% of the population 5

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 6

7 Dental Aesthetics Tooth form Tooth preparation Use all-ceramic to avoid need for subgingival placement of margins Resin cement will avoid this 7

8 Equigingival margins are OK with zirconia based (Lava) crowns Dental Aesthetics Tooth form Tooth preparation Masculinity/femininity Tooth size Tooth colour 8

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 9

10 1974 Today:all-ceramic looks better! 10

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 11

12 Are shade matching devices of value? Shade change can be accomplished by simple procedures Patients must be warned that they will be expected to pay for this normal maintenance Composite restorations almost always need regular finishing and polishing Patient desire for aesthetic restorations is high 12

13 !!!!!!!!! SUMMARY Shade change can be accomplished by simple procedures Sometimes more interventionist procedures are needed Root colour 13

14 Root colour Metal posts corrode, causing root darkening Metal posts disrupt the optimum optical characteristics the of the answer tooth root Metal posts can show through the tooth root if the post hole preparation leaves only a thin rim of tooth tissue 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 14

15 Dental Aesthetics Tooth visibility Ideal tooth alignment 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 15

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 Symmetry Tooth visibility 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 16

17 Symmetry Dental Aesthetics Tooth visibility Symmetry Dental midline Gingival aesthetics Patients views may be Dental different from midline ours! Dental Aesthetics Tooth visibility Symmetry Dental midline Gingival aesthetics Gingival health in adhesive restorations 17

18 What is good aesthetics? Good aesthetics means different things to different people! 18

19 Sadly, some patients choose intervention! 19

20 This is the era of dental aesthetics? Good dental appearance is now in the media spotlight Increasing emphasis on dental aesthetics 20

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 21

22 Peroxide + Perborate Internal Bleaching (Walking Bleach) Direct Composite 22

23 Colour and composite The The more only colours, certain the way more is to beautiful try on the final result? and cure the composite on the tooth 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? 23

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 24

25 Non-destructive dentistry at its best? No chance of pulp death Porcelain Laminate Veneers 25

26 Dentine Bonded Crowns All-ceramic crowns & bridges There are strong positive indications for using aesthetic techniques which are nothing to do with aesthetics P.Hunt, 1987 N.Tulloch, Alness 26

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 Simply having straight teeth does not Upper necessarily incisors guarantee do not touch a lower great lip smile At least 1st premolar to 1 st premolar visible Upper incisor edges are parallel to lower lip (smile arc) 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? 27

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: Underpromise and overdeliver! Yourself! The patient (why cosmetic dentistry, and why now?) The problem The technical procedure and the technician Complex treatment carries risk! AND Keep meticulous records 28

29 Burke FJT, Kelleher MGD J.Esthet.Restor.Dent.2009:21: Burke FJT, Kelleher MGD J.Esthet.Restor.Dent.2009:21: 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? 29

30 Ethical considerations Want vs need Removal Above of tooth all, substance do no harm for elective procedure Clinician should know longevity of procedure (in their own hands) Treatment benefit vs negative consequences Patient s the treatment informed consent is unethical needed If harm exceeds potential benefit, 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: 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. For consent to be valid, patients need to be able to understand. The details of the procedure (?? Show models of preparation??) Alternatives Risks The Time more scale elective the procedure, Costs the more disclosure is needed Bader JD, Shugars DA. Variation, treatment outcomes and practice guidelines in dental practice. J.Dent.Educ.1995:59: ALL spoken in language that the patient can understand Contract Law LAW ETHICS The Law tells you what you can t do, Ethics tells you what you should do! A failure to deliver the higher standard or the promised outcome could be held to be a breach of the contract 30

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 Discuss treatment with options patient: Risk vs Gain vs Cost Talk about costs in s and tooth substance Assess prognosis and future possibilities Use the daughter test! Judge the expected satisfaction on a scale of 0 to 10 (where 10 = excellent aesthetics), and inform patient 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) 31

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 32