Cosmetic dentistry

Cosmetic dentistry

3. Introduction :

The aesthetics of teeth and smiles have become essential for both the patient and the practitioner.

Maintaining or restoring a harmonious smile becomes a constant concern in the practitioner’s daily practice, to the point of being able to speak of aesthetic or cosmetic dentistry.

Aesthetic rehabilitation techniques are detailed and explained to the patient during the consultation, in order to offer them the treatment best suited to their needs.

We must propose a treatment plan that will not only address aesthetic issues, but also address the important functional requirements and complaints of our patients. The approach can be broken down into three steps:

• identify problems
• visualize the individualized solution (in three dimensions)
• choose the appropriate technique to achieve this.

Before establishing our treatment plan, different elements must be analyzed

2. Fundamental criteria in cosmetic dentistry:
   1. Micro-aesthetic elements:

These elements are related to the integration of the smile on the dento-dental and dento-alveolar level

1. Gum health:

Healthy soft tissues require the following:

• The free gingiva extends from the gingival margin (coronally) to the gingival sulcus (apically). It is pinkish in color, with a firm matte surface (keratinized and attached to the underlying alveolar bone) with an “orange peel” appearance in 30 to 40% of adults.
• The alveolar mucosa is apical to the mucogingival junction. It is mobile and dark red in color.
• The attached gingiva extends from the gingival sulcus (coronally) to the mucogingival junction (apically) and has a pinkish coral color and texture.

2. The balance of the gingival festoons:

The gingival scallop of the lateral incisors is slightly more coronal than that of the central incisors and canines.

3. Proportions of the taste buds:

The papilla occupies 40% of the space from the contact area to the enamel-cementum junction of the central incisors and remains constant in volume from the central incisor to the lateral incisor and canine.

4. Dental axes:

The axis of the teeth is inclined from mesial to distal in the inciso-apical direction. This inclination appears to increase from the central incisors to the canines. The position/morphology of the tooth and the gingival contour are interdependent. The six anterior teeth have their roots inclined distally, with the roots of the central incisors approaching the vertical; the inclination increases as one moves distally.

5. The zenith of the gingival contour:

The gingival zenith is the most apical point of the gingival contour. In general, the zenith rule does not apply to laterals; their zeniths are medial. The apex of the gingival scallop appears to be highest at the distal surface of the maxillary central incisor, approximately 1 mm distal to the midline of the teeth. This is often described as a “gull wing” effect. The zenith of lateral incisors and canines, however, should be centered mesiodistally .

6. The interdental contact point:

The situation of the interdental contact depends on the position and morphology of the teeth It is more coronal between the maxillary central incisors It tends to be more apical from the anterior teeth towards the posterior teeth

7. Incisor embrasures:

Between the central incisors, the embrasure represents 20% of the tooth height. It increases by 25%, 30% and 35% as we move distally. Abrasion and wear cause the incisor embrasures to disappear over time; recreating these embrasures will therefore give our patients a more youthful appearance.

8. Contact area:

The contact area between the central incisors starts at 40% of the tooth height and decreases to 30%, 20% and 18% as we go from the central incisor to the lateral incisor and from the lateral incisor to the canine and then distal to the canine.

9. The emergence profile:

This view shows that there are three planes of the tooth from the cementoenamel junction, through the body of the tooth, to the incisal edge.

10. The relative dimensions of the teeth:

The Golden Ratio according to LOMBARDI: In dentistry, the Golden Ratio is a mathematical theorem concerning the proportions of the anterior maxillary teeth. According to this rule, if the width of each anterior tooth is approximately 60% of that of the tooth mesial to it, it can be considered pleasing to the eye. The latest biometric study by Dr. Stephen Chu shows that if the mesiodistal width of the central incisor is X mm, then the lateral incisor should be X − 2 mm, and the canine should be X − 1 mm. Note that X − 1 should represent the entire mesiodistal width of the canine.

11. Texture:

This shows that the lobes of the tooth are formed during development and this happens in both horizontal and vertical directions. This is an element that gives the tooth a more natural appearance, and we must ask the patient if he wants this.

12. Transition lines:

Transition lines give the contour shape to teeth. Adjusting a tooth’s transition lines can make the tooth appear wider or narrower.

13. Outline height:

Contour height (vestibular view): The contour height should be distal to the midline at the gingival third. This vantage point shows that the contour height of the maxillary central incisor is distal to the midline of the tooth.

14. The lower lip line:

The coincidence of the incisal edges with the lower lip is essential for a graceful smile. The proximal contacts, the free edges of the teeth and the lower lip are on parallel lines, which indicates a harmonious situation.

15. Parallelism of curves:

The contact points, the incisal edges and the lower lip should form three curves that echo harmoniously with each other.

2. Macro-elements:
   1. Parallelism

Parallelism between the bi-pupillary line and the line corresponding to the occlusal plane (drawn from the cusp tips of the maxillary canines).

2. Location of the midline:

Location of the facial midline in relation to the midline of the maxillary incisors. This can also be visualized clinically with dental floss.

3. Exposure of teeth at rest:

This is one of the most critical elements of a facially focused treatment plan. From the study by Vig and Brundo, we know that a 30-year-old woman shows 3.4 mm of her maxillary central incisors with the lip at rest; at age 60, the maxillary central incisors are no more exposed, and she shows approximately the same 3.4 mm of her mandibular incisors. A man shows 1.7 mm of the maxillary central incisors at age 30, and the same amount in the mandibular arch at age 60. This decrease in maxillary central incisor exposure is due to the loss of muscle tone over time.

4. Nasolabial angle:

We aim to have a 90° nasolabial angle; thus, an angle less than 90° (maxillary prominence) means that the maxillary anterior restorations should be smaller and less dominant, while an angle greater than 90° (maxillary retrusion) means that the patient can afford to have “raised” maxillary anterior restorations.

5. Ricketts Plan:

Ideally, the upper lip is 4 mm from the Ricketts plane, and the lower lip is 2 mm. If the upper lip is more than 6 mm from the Ricketts plane, then we consider it a concave profile.

3. Recording of aesthetic data:

Obtaining patient X-rays, diagnostic models, bite records, and photographs is essential to help us make a proper diagnosis. These records must be thorough and accurate enough for diagnosis and to create a treatment plan for the entire case without the patient being present.

1. Diagnostic models:

Once the aesthetic assessment sheet has been completed, we move on to the next step: the study models mounted in an articulator, either in centric occlusion (OC) or in centric relation (CR). (See Appendix 1).

2. Aesthetic model:

With the diagnostic wax-up complete, we can now visualize in the mouth our changes made by a direct transfer into the patient’s mouth. Changes made by a direct transfer into the patient’s mouth.

4. Evolution of principles in cosmetic dentistry:
   1. The therapeutic gradient:

For any aesthetic complaint, the practitioner must be able to present to his patient a range of therapies ranging from the least invasive therapy (less destructive of dental tissue) to the most invasive (more destructive of dental tissue) .).

Gil Tirlet proposed a therapeutic gradient which allows the practitioner to situate the aesthetic request of his patient at the level of this gradient.

The choice of treatment will be made after clinical examination, to select the appropriate rehabilitation technique.

• A whitening technique when it comes to lightening the shade of teeth for a bright smile.
• A microabarsion or macroabarsion.
• Orthodontic treatment to align teeth in cases of malposition or crowding.
• An aesthetic restoration using composite or ceramic material when there is damage to the integrity of the tooth.

A surgical technique (graft and flap).

2. The physiological puzzle: the concept of biomimetics:

In contemporary dentistry, the concept of “biomimetics” is a true synonym for the natural integration of biomaterials: that is to say, they are simultaneously biological, biomechanical, functional and aesthetic, mimicking as closely as possible the physiological behavior of natural teeth.

Biomimetics thus combines two fundamental parameters at the heart of current therapies: tissue preservation and adhesion

3. The practitioner must adopt three very different but closely linked attitudes :

• Observe the natural tooth : its biology, its function, its mechanical behavior and its optical properties.
• Respect the natural tooth : by developing minimal preparations of dental tissue.
• Copying the natural tooth : using adhesion and current biomaterials (composite and ceramic).

5. Digital Smile Design Digital Smile Design:

The aesthetic assessment sheet serves as an introduction to understanding the patient’s needs and wishes, followed by an examination of the facial, dentofacial, and dental views. A camera is used to show the facial view, analyzing its general anatomical shape and symmetry.

The next step is the dentofacial view, where the positioning of the lips in relation to the teeth is analyzed, then the dental view, which allows the assessment of shade, tooth shape, translucency, brightness, gingival zenith levels and other micro-aesthetic elements. After obtaining a complete series of photographs, a “retrograde” digital planning is initiated, using the digital design process of the s .

The digital smile design can be tested virtually by simply sectioning and bonding the new teeth into the patient’s oral cavity. The positioning of the lips, gingival zeniths, and the shapes and sizes of the teeth are examined. If the practitioner and patient are satisfied, the diagnostic wax-up can be created, along with an intraoral model.

Conclusion : The evolution of materials and new techniques are bringing cosmetic dentistry into a new era of digital dentistry.

Appendix 1:

APPENDIX 2

Annex 3

Bibliography:

1. Biomimetic Restorative Dentistry, Volume 1.Fundamentals and Basic Clinical Procedures. Magne, Pascal, author. 1 Belser, U., author.
2. Biomimetic Restorative Dentistry, Volume 2 Advanced Clinical Procedures and Maintenance. Magne, Pascal, author. 1 Belser, U., author.
3. Cosmetic Dentistry: The Smile Jonathan B. Levine
4. https://www.smilecloud.com/download?network=g&source

Cosmetic dentistry

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Cosmetic dentistry