Anterior dental esthetics /academy of cosmetic dentistry

ANTERIOR DENTAL
ESTHETICS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
• Introduction
• Definitions
• Physical attributes of the elements of the dentofacial
composition
• The art of illusion
• Esthetic diagnosis and treatment planning
• Role of technology in changing smile
• Esthetic treatment planning and sequencing
• Color
• Treatment options
• Review of literature
• Conclusion
• References

INTRODUCTION

In our modern competitive society, a pleasing
appearance often means the difference between
success and failure in both our personal and
professional lives.
Scottish physiologist Charles Bell was quoted as
remarking that the thought is to the word that the
feeling is to the facial expression.
A smile could convey a thousand different meanings ,
yet it is the most easily recognized expression.

A charming smile can open doors and knock down
barriers.
An attractive or pleasing smile clearly enhances the
acceptance of the individual in the society and the
character of the smile influences to a great extent the
attractiveness and the personality of the individual.

But every person is not fortunate enough to have a
beautiful smile . The answer to the above problem is
the esthetic dentistry which has developed leaps and
bounds with the latest technologies and materials.
Prosthodontist is probably the best person to identify
the quality of smile. Further he is also able to change
the quality of smile with the recently available
innovative techniques and the state of art restorative
materials and to plan restorations, to harmonize with
the smile.

CLASSIFICATION OF SMILE (Solomon E.G.R.)
1) Depending on the nature of labial mucous
membrane
a) papilla smile
b) Gingival smile
c) Mucosa smile
2) Depending on the lip component
a) Straight smile
b) Convex smile
c) Concave smilewww.indiandentalacademy.com

Esthetics
-the branch of philosophy dealing with beauty
-in dentistry, the theory and philosophy that deal
with beauty and the beautiful, especially with respect
to the appearance of a dental restoration, as achieved
through its form and / or color.
Esthetic Dentistry
can be defined as the art and science of dentistry
applied to create or enhance beauty of an individual
within functional and physiological limits.

Cosmetic dentistry
application of the principles of esthetics and
certain illusionary principles, performed to signify or
enhance beauty of an individual to suit the role he
has to play in his day-to-day life or otherwise.
Smile designing
is a process whereby the complete oral hard and
soft tissues are studied and evaluated and certain
changes are brought about which will have a positive
influence on the overall esthetics of the face.

Physical attributes of the elements of the
dento-facial composition
The artistic parameters to be considered for essential
beauty and those which are subtly present in natural
beauty form the fundamental principles of esthetics.
Understanding these artistic parameters of beauty and
co-relaing them to the dento-facial complex will enable
the dentist to appropriately scale esthetics in any
dento-facial composition.

Composition means the act of
combining elements or parts to form a
whole. There are various physical
attributes of the elements of a
composition that impart the esthetic
value.
The various physical attributes of the
elements of the composition are as
follows-

Contrast:
It is that factor which makes the various elements of
a composition visible. The eye can differentiate the
parts of an object due contrast of colors,lines,
patterns, textures, etc. The relationship between the
different parts of the face (facial), the teeth and the
gums (dental) made visible by contrast constitutes
the dento-facial composition.

Unity or oneness:
“It gives different parts of the composition the effect
of a whole”. Unity can either be static, when repeated
shapes or designs are seen as in inanimate things, like
the composition of crystals; or dynamic and changing
as in living beings. Unity between different parts of
the face, and teeth is essential to give the effect of
oneness or wholeness to the dento-facial composition.

Cohesive and segregate forces:
Any element which tends to unify a composition
is a cohesive force. Segregative forces are those
elements which break the monotony of the
composition. Naturalness has combination of
cohesive and segregative forces. A proper mix of
segregative and cohesive forces adds variety to the
composition making it more dynamic and
interesting

Symmetry:
It is the regularity of arrangement of forms either
from left to right as in horizontal symmetry, or
from a central point to either side like a mirror
image as in radiating symmetry. The horizontal
symmetry looks repetitive and uninteresting while
the radiating symmetry looks dynamic and
interesting. In a dento-facial composition radiating
symmetry of the teeth is more esthetically appealing
and is associated with youthfulness while horizontal
symmetry is less appealing and is associated with
aging.

Proportion:
The proportion between the various elements of
a harmonious composition, in which the cohesive
and segregative forces are equally balanced,and
which has its various units in an esthetically
appealing respective proportion to each other is the
golden proportion

Dominance:
It exists when a strong centralized
structure is surrounded by well-demarcated,
characterized structures. In a dento-facial
composition it creates immaculate unity leading to
a harmonious composition.
The absence of dominance makes the
composition weak. Color, shape and size are the
factors which can control dominance).

Balance:
It is achieved when there is an exact equilibrium
between the forces present on either side of the
fulcrum in a composition. In dentistry this implies the
balance of the elements in relation to the midline.

Visual tension
is the tension brought about by the presence of
certain elements that cause an imbalance in the given
composition. If the presence of these factors is closer to
the fulcrum, the tension induced is more magnified as
against their presence farther from the fulcrum.

The esthetic orientation of the dental composition
with the entire facial composition can be achieved
by taking into consideration the
-- references,
-- smile elements,
-- proportions and
-- symmetry.

The dento-facial frame constitutes the teeth and
gingiva related to the lips and then to the entire face.
The oral frame is determined by the anatomy and
mobility of the tissues when in function surrounding
the teeth and gingiva .The exposed portion of the oral
elements i.e. teeth and gums within the oral frame
during a smile is called the smile window.
.

References can be classified as
-- horizontal references,
-- vertical references,
-- sagital references and
-- phonetic references.

Horizontal references:
The horizontal perspective of the face is
provided by the interpupillary line the
commissural line.
The inter-pupillary line helps to evaluate
the orientation of the incisal plane, the gingival
margins and the maxilla. An imaginary
horizontal line through the incisal plane and the
gingival margins should be visibly parallel to the
inter-pupillary line. This helps to diagnose any
asymmetry in the tooth position or gingival
location.

Vertical references:
The facial midline serves to evaluate the location
and axis of the dental midline and the medio-
lateral discrepancies in tooth position.The inter-
pupillary line and the facial midline emphasize the
‘T’ effect in a pleasing face. The dental midline, if
perpendicular to the inter-pupillary line and
coinciding with the bridge of the nose and the
philtrum, produces an attractive orientation of the
smile.

Axial inclination
is the direction of the anterior teeth in relation to
the central midline and becomes progressively more
pronounced from the central incisor to the canine.
There is a definite mesial inclination to all the
anterior teeth related to the midline. The axes of the
premolars and the first molar on either side also
show mesial inclination in relation to the midline.

The perception of tooth inclination can be
viewed from the frontal aspect around the central
vertical midline, which acts like a fulcrum around
which axial inclination of teeth on either side exhibit
a phenomenon of balance of lines. Deviations in axial
inclination cause a visual tension when beyond the
point of equilibrium

Sagittal references:
Soft tissue analysis at a standardized position
helps in studying the profile of an individual. The
contours of the upper and lower lip support is
determined by the position of the anterior teeth and can
be used as a guide for the placement of teeth when
planning restorations. The lip protrusion, the amount of
prominence of chin, recession or prominence of the
nose and its degree, all help in profile analysis for
diagnosis and treatment planing.

The E-line or esthetic line is an imaginary line
connecting the tip of the nose to the most prominent
portion of the chin on the profile, ideally the upper lip
is 1-2 mm behind and the lower lip 2-3mm behind the
E-line. Any change in the position of the E-line
indicates the abnormality in the upper or lower lip
position.

The relationship of the maxillary incisl edges to the
lower lip is a guide for the placement of the incisal
edge position and length. The pronunciation of the
‘F’ and ‘V’consonants helps determine the position
of the incisal edges. On pronouncing ‘F’ and ‘V’ the
incisal edges should make a definite contact at the
inner vermilion border of the lower lip Thus the
position of the incisal third of the maxillary central
incisor can be determined.

Phonetic references:
‘F’ and ‘V’ sounds are used to determine the tilt
of the incisal third of the maxillary central incisors and
their length. The ‘M’ sound is used to achieve relaxed
rest position and repeated at slow intervals can help
evaluate the incisal display at rest position ‘S’ or ‘Z’
sounds determine the vertical dimension of speech.. Its
pronunciation makes the maxillary and the
mandibular anterior teeth come in near contact and
determine the anterior speaking space

Smile elements:
The extent of the smile is outlined by the curvature of
the upper and lower lip and the position of the angle of
the mouth, and it determines the degree of exposure,
both in the anterior and posterior teeth, gingiva as well
as the width of the buccal corridor

Lip and lip lines:
The length, the curvature and the shape of the lips
significantly influence the amount of tooth exposure
during rest and in function.
A prominent tooth display is associated with a
youthful smile and most patients would like to seek the
benefit of the same. Some researchers demonstrated that
the average maxillary incisor display with the lips at rest
is 1.91mm in men and 3.40 mm in Women Patient’s
with short upper lips and younger patients generally
display more maxillary tooth structure which may be up
to 3.65mm.

Upper lip line helps to evaluate the length of the
maxillary incisor exposed at rest and during smile and the
vertical position of the gingival margins during smile.
The upper lip line can be classified as low, medium or
high depending upon the amount of tooth or gingival
display that is available during a moderate smile. The
gingival margins may be displayed in high lip line cases.
The most apical position of the gingiva over the facial
aspect of the maxillary central incisor and canine is
slightly distal to the long axis of the tooth while in the
maxillary lateral incisor it is at the long axis of the tooth.
This is called the gingival zenith

Whenever a patient displays the gingival margins
easily on smiling or speaking, a definite pattern of
the gingival display can be recorded. This pattern
can be either esthetic or unesthetic A smile can be
termed “toothy” if more than 6mm of incisal
display is seen at rest position or “gummy” if more
than 3mm of gingival tissues are displayed in
moderate smile)

Lower lip line
helps to evaluate the buccolingual position of the
incisal edge of the maxillary incisors and the
curvature of the incisal plane

Smile line:
It is an imaginary line passing through the incisal edges
of the upper anterior teeth.
The smile line usually coincides or runs parallel to the
inner vermilion border of the lower lip.
In a youthful smile the incisal edges of the central
incisors and canines are aligned on a convexity, incisal
embrasures gradually deepen from central incisor to the
canine, giving the appearance of the wings of a gull. Thus
the incisal plane is said to have a gull-wing appearance
Reduced incisal embrasures and leveling of the gull-wing
effect as in a straight smile line is associated with aging.www.indiandentalacademy.com

Negative space:
Negative space is a dark space appearing between the jaws
and the mouth opening either at the corner of the mouth of
around the buccal aspect of the posterior teeth during
active smile and laugh.

Progressive abating in a dental composition:
When similar structures are aligned in an
arch form one after the other, they appear to
progressively abate in size from the nearest to the
farthest. This gives an illusion of depth.
The presence of poorly shaped teeth,
differences in axial inclinations, tooth length
discrepancies, discolorations, gingival disharmonies
etc. can lead to a visual tension resulting in a
disruption of the front to back progression.

Proportion
When mathematics is applied to the study of
ideal tooth form, a numerical relationship is
established within a single tooth form (ideal
proportion) and also between a series of teeth in the
arch (relative proportion). The position of the tooth
in the arch, the relationship between the width, the
length and the face of the tooth can also be
numerically established in relation with certain
anatomic landmarks.

Gold Proportion
is expressed in numerical form and applied by
classical mathematicians such as Euclid and
Pythagoras in pursuit of universal divine harmony
and balance. It has been applied to a lot of ancient
Greek and Egyptian architecture and may be
expressed as the ratio 1.618:1:0.618

Symmetry
For harmony, certain symmetries are essential
while certain asymmetries are acceptable.
Harmonious facial features should be more
symmetrical close to the facial mid line and can be
more asymmetrical away from the facial midline.

Smile Dominance :
Different facial features stand out differently in the
eyes of every beholder. In certain cases, the most
predominantly striking features of a face is the smile;
these are the “Dominant Smiles”.
• The maxillary central incisors exhibit a strong
presence by their size and form reflecting the
personality of the individual.
• The maxillary lateral incisors and the canines
complement the cement incisor in terms of proper
shape and form.

PERCEPTUAL ASPECTS – THE ART OF
ILLUSION
Illusion is an imagination where a perception of
an object is created.
Fundamental and Principles
The art of creating illusions consists of
changing perception, to cause an object to appear
different from what it actually is. Teeth can be made
to appear smaller, larger, wider, narrower, shorter,
longer, younger, older, masculine or feminine.

One being subjected to light the most
fundamental objects exhibits two dimensions,
that is, length and width. True natural light is
multi-directional and on striking the surface of
the object, also reveals texture and shadows,
this adds the third life like dimension of depth.

Cosmetic contouring
Cosmetic contouring by definition is the
reshaping of natural teeth to make them esthetically
pleasing.
In natural dentitions, variations seen in tooth
shape and size some times violate the acceptable
width to length ratios as well as the golden
proportion. Minor adjustments in contours to
change the perception of these proportions increases
the esthetic acceptability to a great extent. It is
indicated for giving a pleasing appearance to
fractured, chipped, extruded, malformed or over
lapped teeth www.indiandentalacademy.com

ESTHETIC DIAGNOSIS AND TREATMENT
PLANNING
Total Smile Analysis
Total smile analysis is a cumulative inference analysis,
drawn by interpreting and integrating various analysis
like a visual , space ,profile and computer analysis after
performing the preliminary analysis.

Space Analysis
It helps the dentist to gauge the amount of
space available during the treatment planning stage.
The concept is to measure the widths of all the teeth
and to compare it with space present in the arch.
This determines whether the space available for
restorations and natural teeth is less or more than
required.
Disproportionate spaces may be due to
discrepancies in jaw and tooth size, malformed teeth,
missing teeth, mal-aligned teeth etc. The space
analysis will provide a guideline or a frame work
within which the esthetic dentist has to plan each
restoration. www.indiandentalacademy.com

Corrections of labio-lingual inclinations and rotations
of the teeth by restorative procedures will result in a
change in the width space ratio due to the change of
angulation involved.
For any changes proposed that may
involve alterations in the width of the anterior teeth,
the law of golden proportion should be closed
followed. This enables the esthetic dentist to plan any
space manipulations for the restorations in terms of
illusions, actual tooth positional changes such as
rotations overlaps, spacing etc.

Profile analysis
While examining the patients profile, the normal
profile is referred to as straight orthognathic. Any
deviation from this should be recorded and considered
in treatment planning.

Profile analysis helps in treatment planning of
the cases that will require skeletal correction in
addition to the esthetic restorations for complete
esthetic success. This will ensure that the skeletal
and non-skeletal aspects of the treatment plan are
segregated and treated for a comprehensive,
successful esthetic treatment.

Computer Analysis
The new intra-oral cameras with digital support
and the radio-visiographs are indispensable tools at
the esthetic dental office. They give enlarged images of
the photographic and radiographic outputs on the
screen, with multiple magnifications, and at various
angles, for the dentist as well as the patient to assess
and view the intra oral condition in a different
perspective.

ROLE OF TECHNOLOGY IN CHANGING
SMILE
New technology helps us to preview the end
results.The following high tech tools can be
incorporated:
1) Extra oral video camera: It allows to have a
detailed record of the patient's face while moving and
talking. It can record the patient in various moods and
gestures and give us the minute details the patient
may be unaware of. This can be shown to the patient
with the help of computer imaging . Different smiles
and profiles can be applied to the patient's face and
the patient can be given the opportunity to choose the
best smile design

2) Intraoral video camera:
Intra oral examination from every angle with the
smallest details can be viewed as close as 2mm. from
the tooth. With it we can explain certain conditions
and treatment options much more accurately.
Introral cameras can be integrated with a computer
imaging system to capture the detailed images of the
patient's oral cavity. These images can be modified
according to the proposed treatment options and
shown to the patient.

3) Computer or voice activated data
Using voice activated technology , we can
document our findings by speaking into the
microphone that are connected to a computer
which has been "trained" to recognise a limited
vocabulary. The computer then stores the
infomation and even graphics( related to smile ) so
that various procedures can be discussed with the
patient.

4) T- Scan and Digital Radiography
By using this scan , buccolingual width of the
jaws as well as the location of anatomic features such
as the mandibular canal and the maxillary sinus can
be determined which is useful while placing an
implant in the esthetic position.

5) CAD/CAM
With CAD/CAM ( Computer assisted design/
Conputer assisted manufacture) technology we can
design veneers and crowns to enhance smile while the
patient waits. The so called "mock- up" of a planned
cosmetic teatment also has been shown to be quite
useful. It also allows clinician to visualise the desired
results and solve potential problems before providing
treatment to the patient.

6) Lasers
The dental lasers uses a beam of light in place of
scalpel to perform delicate gum surgery and crown
lengthening/ gingivectomy and gingivoplasty.
The advantages of this procedure are-
1) Controlled bleeding which provides dry
operating field and hence excellent visibility.
2) Reduced operating time and reduced post
operative swelling, pain and scarring.

7) Computer Imaging
It improves communication between the
patient and the dentist by allowing both to
visualize , evaluate and agree on treatment. It
allows to " see" various looks before deciding
upon treatment.

8) Computer Controlled Injection Technique
The P- ASA (Palatal approach anterior superior
alveolar ) is a new block injection technique that
provides anaesthesia of the maxillary anterior teeth
from a single injection without numbness of the face ,
lips and the muscles of facial expression. The injection
can be administered in a comfortable and consistent
manner, using a computer controlled local anaesthetic
delivery system. This technique prevents distortion of
the smile line and enhances restorative procedures
that use the lipline as an esthetic reference element.

9) Abrasive Technology
In this technique , a jet air stream with micro
abrasive particles is used to remove the stained areas.
It is painless, faster and does not require the use of
anesthesia. It can be used in any quadrant for any
depth of decay without damaging the healthy tooth
structure. After the removal of the stained areas , the
tooth structure can be built up with composite.
It is also useful during repairs to existing
composite or porcelain restorations because it
roughens these surfaces allowing the reparative
materials to bond them more rapidly .

COLOR
Dimensions of color
Color cannot be perceived without light,
which is a form of electoro-magnetic energy visible
to the human eye. The visible spectrum of light lies
in a narrow band of 380nm to 760nm. It has the
ability to stimulate the cells in the retina which is
interpreted by the brain, discerning the sense of
color.

Clark stated that “Color, like form, has three
dimensions”. Hue, which is the name of the radiant
energy, Chroma, which is the saturation of the hue
and value, which is the relative lightness or darkness
of the color. Since clinical color matching depends
upon the ability of the dentist to perceive the
difference in the tooth shade guide comparison;
complete understanding of the color dimensions is
critical.
The Munsell color order system best serves
the needs of the dental profession in its attempt to
visualize and organize color.

Hue : In Munsell’s words, “It is that quality by
which we distinguish one color family from anther”.
Chroma :In Munsell’s words, “it is the quality
by which we distinguish a strong color from a weak
one. “Human teeth fall into the yellow to yellow red
area of the Munsell color order system. Pale colors
have a low chroma whereas intense colors have high
chroma.

Value : Value or brilliance is the relative blackness or
whiteness of color. On a scale of black to white, white
has “high value”, black a “Low value” and Midway
between black and white is the medium grey.

Shade selection
Shade selection is a complex procedure due to
the variations and differences in the optical
properties of the new generation of cosmetic
restoration materials. It can be well accomplished by
understanding the fundamentals of color and
adopting a proper methodology of matching shades.
The effective communication with the laboratory and
precise fabrication and meticulous finishing of the
restoration will affect the color of the final
restoration.

Shade selection sequence
Any color modification procedures like
bleaching or microabrasion should precede color
selection after ensuring color stabilization.
• Make the shade selection at the beginning of the
procedure as well as over different appointments
(diagnosis, prophylaxis etc.)and cross check these
observations.
• View the patients at eye-level. The operator
should stand between the light source and the patient.
• In a contrasting environment, colors look more
intense and brighter. Hence it is wise to ask the
patient’s to remove artificial lip color.www.indiandentalacademy.com

• Place the tabs as close as possible to the area
that is being checked.
• Moisten the tab and eliminate the worst
match.
• Evaluate the value (upper to lower). Value is
the most important factor in shade matching. If the
value blends, small variation in hue and chroma will
not be noticeable. The value is to be matched with
eyes half closed.
• After value, mark the translucency
• Match the chroma (more or less saturated)
and finally, hue in that order.

Dental Bleaching
Bleaching is one of the most commonly sought
elective dental procedures to brighten a smile. It is a
simple, fast and effective treatment to change darker
tooth shades into lighter ones.
Chemistry of bleaching
Bleaching process is based on the oxidation of
bleaching agent. Oxidation is the chemical process by
which organic materials are converted into carbon
dioxide and water. The oxidation reduction reaction
that takes place in the bleaching process is called the
redox reaction.

Office bleaching of non vital teeth
The two most commonly used agents for bleaching of
non-vital teeth are hydrogen peroxide and sodium
perborate.
Home bleaching
Bleaching may be carried out at home by the patient.
The home bleach technique involves the application of
bleaching agent through the use of vacuuform trays. The
frequently used bleaching agent is 10% - 15% carbamide
peroxide.

Esthetics with composites
The preparation design for anterior composite
restorations should encompass elimination of decay,
function and longevity, and esthetic predictability.

To create proper tooth from, shape, shade and
texture, and to optimize function, all cavity
preparations designs should have extension for
function and esthetics (EFE).

The Extension for Function and Esthetics ensures
that the margin of the restoration overlays the
defects. The esthetic advantages are :
• Successful masking of the defect
• Better marginal adaptation
• Natural transition of shade between composite
and tooth
• Ease of finishing and texturing

Esthetics with Ceramics
Ceramics laminate veneers
In 1930 Charles Pincus used a unique
procedure to improve the smiles of certain Holly
wood actors. This technique was non-invasive and
gave good esthetic results with resin and air fired
ceramics.

Metal ceramic and all-ceramic restorations
Metal ceramic and all ceramic restorations have
excellent esthetic potential. The metal ceramic
restorations owe their popularity to the simplicity of
bridge construction, durability, strength, marginal
adaptation and versatility of use.

Pre-implant esthetic consideration
In cases of anterior implants in the esthetic zone,
certain specific esthetic criteria have to be considered.
When esthetics is the prime reason for seeking implant
prosthetic treatment, the patient’s upper lip line will be
of extreme importance for the planning of the definitive
superstructure.

The single tooth anterior implant situations is of great
concern as the esthetic requirements and expectations
have to be properly balanced keeping in mind anticipated
post-surgical results. The dentist should analyze anterior
single tooth implant situations considering the adjacent
teeth, contra-lateral tooth, probable emergence profile
and presence or absence of inter dental papilla whenever
the active smile exposes enough of gingival tissues.

Apart from the inadvertent deficiencies in the
facial bone associated with various clinical
situations, the soft tissue form also plays a major
role in the esthetic outcome of single tooth
implants.
In 1989, Misch reported 5 prosthetic
options available in implant dentistry. The first
three options are fixed prosthesis (FP). The next
two options are removable prostheses (RP).

Prosthodontic classification
FP – 1Fixed Prostheses, replaces only the crown, looks like
a natural tooth.
FP – 2Fixed Prostheses, replaces the crown and a portions
of the root; crown contour appears normal in the occlusal
half but is elongated or hyper contoured in the gingival
half.
FP – 3Fixed Prostheses ; replaces missing crowns and
gingival color and portion of the edentulous site; Most
often uses denture teeth and acrylic gingiva, but may be
porcelain too

RP – 4 Removable prostheses ; over denture supported
completely by implant.
RP – 5 Removable Prostheses ; over denture supported by
both soft tissue and implant.

Esthetic periodontal defects and its correction
Periodontal defects posing an esthetic problem.
May include :
• Violations of biologic width
• Gingival asymmetries
• Excessively gingival display
• Localized gingival recessions
• Deficient pontic areas
• Abnormal frena.
• Excessive gingival pigmentation
• Inadequate interproximal papilla

The possible causes of gingival asymmetries are :
• Gingival hyperplasia
• Altered passive eruption
• Tooth or teeth malpositioning
• Over zealous tooth brushing
• Periodontal disease

Impaired dento-facial esthetics and function
due to absence of canines.
The position of canines in all three planes of
space is very important from esthetic and
functional point of view. The ectopic eruption and
impaction of maxillary permanent canines is a
frequently encountered clinical problem.
The canines also provide the main gliding
inclines for lateral excursions of the
mandible.Thereby providing the patient with a
functional occlusion.

Therefore, it is not only important to
get healthy favorably positioned
impacted teeth into occlusion but also to
position them in such a way that they
maintain the integrity of occlusion,
provide good function and optimal
esthetics.

Establishing proper anterior guidance
Proper inter-incisal relationship is
important to maintain the vertical position of
incisors. Loss of this relationship leads to supra-
eruption of incisors and deep bite.

In severe deep bite case, there is often attrition of
lower incisal edges and the palatal surfaces of upper
incisors, leading to shorter clinical crowns of the lower
incisors and lack of anterior guidance. In such a
clinical situation, if there is any restoration in the
maxillary anterior region, it will have a tendency to
debond due to lack of sufficient vertical clearance.

Therefore, it is necessary to establish proper
anterior guidance with orthodontics so that the
palatal surfaces of upper anteriors could
provide a harmonious glide path for the lower
anterior teeth during the protrusive excursion
of the mandible. These teeth should work
against one another to separate or disocclude
the posterior segments as soon as the mandible
moves out of centric closure.

Ortho-Perio –Restorative Perspective
An integrated orthodontic, periodontal
and restorative treatment is useful in wide
variety of patients for improved occlusual
relationships of teeth, proper gingival
architecture and esthetic, biologically sound
restorations.

During the process of eruption the whole periodontal
apparatus is carried with the erupting tooth. When there
is asymmetric eruption of the teeth it will also result in
discrepancies in heights of the underlying crestal bone.
This, in turn, results into asymmetries in gingival heights
(gingival zenith) from one side of the arch to the other.
This type of a clinical situation can be managed
orthodontically by intrusion or extrusion of teeth.
Forced eruption
Forced eruption is one of the adjunctive orthodontic
treatment procedures where controlled vertical extrusion
of a tooth is carried out to improve the prognosis of other
treatment procedures.www.indiandentalacademy.com

REVIEW OF LITERATURE
• E M Narcisi, J A DiPerna ; highlights the harmonious
integration of modern smile design, material selection, and
interdisciplinary communication that must be addressed in
order to deliver optimal treatment with porcelain laminate
veneer and laboratory-fabricated resin inlay restorations. J
Esthet Dent Assoc 2001
• Singer BA. introduced to the literature a framework for
understanding artistic principles as they relate to clinical
cosmetic dentistry, ie, shaping teeth and creating illusions
J Esthet Dent Assoc 1994

• Carlos Eduardo Francischone et al ; stated that with the
integration of many specialities, it is possible to achieve
the desired esthetics for anterior prostheses and to
develop a harmonious transition to the surrounding
periodontium. JPD 2000
• Roy Sabri ; concluded that missing maxillary lateral
incisors with any coexisting malocclusion must be
managed within an overall treament plan. JIPS 1999
• Messing MG ; Factors related to patient , size, shape and
position and color of the teeth ; the effect of occlusion;
the overall facial and dental esthetics should be
considered when deciding on whether to create an
orthodontic space opening or space closure. J of Esthet
Dent, 1999

CONCLUSION
• Dentistry is an ever changing science. As new research
and clinical experience broaden our knowledge,
changes in treatment are required. This shift in the field
of dentistry comes along just in time to meet the final
needs and wants of patient who perceives an attractive
smile no longer as a luxury but rather a necessary part
of their life style.
• Aesthetic dentistry enables the dentist to change the
appearance, size, color, shape, spacing and positioning
of the teeth.

REFERENCES
• CLAUDE R. RUFENACHT, fundamentals of esthetics
• RONALD E. GOLDSTEIN, change your smile 3rd
ed.
• CHICHE, esthetics of anterior fixed prosthodotics
• GOLDSTEIN, complete dental bleaching.
• GARDIN, Porcelain laminate veneers
• Solomon EGR: Esthetic consideration of smile; J of IPS
1999: 10(3&4); 41-47
• Goldstein, RE: Change your Smile, ed 3 Chicago,
Quintessence, 1997.
• Messing MG The role of cosmetic dentistry in restoring
a youthful smile: J of Esthet Dent, 1999

• Kamal Shigli, Swaraj Bharati: Role of
technology in designing a confident smile. J. IPS
Dec. 2001, vol.1, no.4.6)
• Friedman, MJ and Hodcman, M.N.: P-ASA
Block injection: Anew palatal technique to
anaesthetize jmaxillary anterior teeth: J of Esthet
Dent, 1999; 11(2): 63-77.

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