Chapter 2 Esthetic Considerations in Dental Restorations

Esthetic Considerations in Dental Restorations

Esthetics is the study of beauty. In dentistry, it is that part of science that deals with
giving artificial restorations a natural appearance. Dental esthetics is a function of
harmony between the facial muscles, the jaws, bones and teeth.

I.General Factors influencing Esthetics:

Our perception of dental esthetics is greatly influenced by cultural and artistic

factors.

A. Cultural influence:

Culture is developed from the surrounding environment. We conclude from

observing that age and gender influence our expectations of tooth size and form.
Ex.Older teeth are darker, longer and worn due to attrition and gingival recession.
While, feminine teeth are expected to be smooth with rounded corners, white and
small in size.

B. Artistic influence:

Is developed unconsciously and influences our perception of form and size.

Illumination and lines in objects are the main influencing factors.

Principle of Illumination:

Light areas in a restoration appear in a more foreword position while dark

areas appear to recede. This concept gives depth or the third dimension to the
restoration.

Principle of Line:

Artists draw within a frame. Inner frames are subsequently drawn and related to
each other with imaginary reference points. To develop a sense of alignment certain
guidelines ex lines, help to develop references, harmonious orientation and
arrangement.
 Chapter 2 Esthetic Considerations in Dental Restorations

Interpupillary line

Vertical Reference Lines: Fig (1)

Facial midline serves to evaluate and locate the dental midline, and mediolateral
tooth position. Logically the maxillary central incisal midline should coincide with
the midline of the face.

Horizontal Reference Lines:

1. Interpupillary line:
2. Lip line.
3. Smile line/ Incisal plane.
4. Gingival Form

Strict parallism is not required, however it must be determined whether they

conflict or not with the general horizontal perspective of the face.

Interpupillary Line:

The incisal plane of maxillary teeth and gingival margin must be parallel to the
interpupillary line. This is further reinforced by the incisal plane following the lower
lip during smiling.

Optical Illusion and surface characterization:

i. Principle of line:

It is the art of changing perception by using the above principle. In other words the
principle of line can be used to create the illusion of longer or shorter tooth.
Horizontal lines makes an object appear wider, whereas vertical lines make an
object appear longer. Stain lines, texturing and modifying the incisal edge contribute
to illusions.
 Chapter 2 Esthetic Considerations in Dental Restorations

Fig ( 2 )

ex horizontal lines created by cervical staining or white hypoplastic lines create the
illusion of width, while vertical stain lines, vertical surface irregularities (texture) or
deepening of the incisal embrasures give the illusion of length. (Fig 2)

ii. Principle of Illumination:

Light approaches and dark areas appear to recede.

Proportion:
Early on beauty was associated with harmony of proportion ie it could be stated
that idealism and proportion were the guidelines.

Symmetry:
Unconsciously we expect to perceive facial symmetry. This perception of order in
the face depends on parallel lines, symmetry and recurring ratios.

II. Dento_Facial Complex:

Appearance zone / (Oral Frame):

The oral frame including the lips, teeth and soft tissues occupy one third of
the face. The aim of esthetics is to create teeth of pleasing proportion to one
another and arrange them in harmony with the gingiva, lips and face of the
patient.

Harmonious incisal plane fig(3) Inclined incisal plane fig(4)

Appearance Zone
 Chapter 2 Esthetic Considerations in Dental Restorations

Attractiveness results from a general sense of symmetry, balance, and harmony

between structural facial features. Teeth interact and must be in harmony with 3
frames face, lips and the gingiva.

Factors affecting Oral esthetics:

1. Lip line.
2. Smile line/Incisal plane.
3. Gingival Form
4. Functional Requirements.
a. Phonetics.
b. Anterior Guidance.
5. Facial relationships and proportions:
a . Symmetry
b .Golden ratio.

1. Lip Line:

The length and curvature of the lips influences the amount of incisal display, at
rest and in function. A prominent smile with bright teeth is linked with youth.
The incisal display at rest depends on the length of the upper lip, age and sex of the
patient. Ex. The average display of a young female is 3.5 mm and 1.9 mm for men.
Full concave lips result in large display of maxillary teeth.

Full concave lips allow prominent display

of maxillary teeth and are associated with youth.
Fig ( 5 )

The Upper lip serves to :

a. Evaluate the length of maxillary incisor exposed at rest.
b. The position of the gingival margins during smile.

The Lower lip affects:

a. The buccolingual position of the incisal edge of maxillary incisors.
b. The curvature of the incisal plane .Mx incisal plane parallels the lower lip.
 Chapter 2 Esthetic Considerations in Dental Restorations

2. Incisal plane /curve :( Smile Line)

An esthetically pleasing incisal curve (plane) should be perpendicular to the midline,

& parallel to the inter-pupillary line. The incisal plane is composed of the incisal
edges of the maxillary anterior teeth and parallels the inner curvature of the lower
lip.

The incisal plane maybe:

 Straight: associated with age and attrition. Fig ( 6)

Straight incisal line (Fig 6)

 Convex Fig (7) Incisal edge of central incisor& cusp tip of canine lie on the same
curved line.
 Concave (reverse smile line) and is formed when the canines are longer than the
central incisors. It is displeasing and unattractive. Fig (8 )

Smile Line

Convex Fig (7) Concave (reverse smile line) Fig (8)

3. Gingival Form:

The amount and level of gingival margins exposed during a smile can greatly
influence the final esthetic outcome. Gingival form, color, texture and health also
influence esthetics. In addition, orientation in relation to the interpupillary line and
upper lip line plays a role.
Irregular gingival margin

More than 3mm

of gum exposed

Gummy smile (8) Displeasing level of gingival margins (Asymmetry)fig (9)

 Chapter 2 Esthetic Considerations in Dental Restorations

 Moderate gingival exposure →varies between no gingiva seen up to 3mm of

gingival display, beyond that a gummy smile which is very unesthetic is produced.
Gummy smile→ more than 3mm of gingival tissue is displayed.

Special attention should be given at the time of tooth extraction in order to

preserve the bone volume and inter-dental papilla at that area.
Severe asymmetry needs surgical correction before prosthetic treatment.

4. Function:

A. Phonetics:

The length of maxillary incisors affects both phonetics and anterior guidance.
To insure the correct length of maxillary incisor teeth ask the patient to sound the
letter (F) or (v).It should place the maxillary incisal edges against the inner edge of
the vermilion border (The wet-dry line) of the lower lip. (Fig. 10-a)
The length of maxillary incisors is determined by:
i. Phonetics.
ii. Anterior guidance
iii. Upper lip.
iv. Lower lip.

Fig. (10 -a) F sound position

Fig. (10-b) S position

Incisal edge of mandibular incisors is established by:

Occlusal contact with maxillary incisors should be 1 mm behind and below the edge
of maxillary teeth when pronouncing an “S “.
 Chapter 2 Esthetic Considerations in Dental Restorations

B. Anterior Guidance:

The incisal edges of mandibular incisors are established both by occlusal contact
with the maxillary incisors and by their position 1.0 mm behind and 1.0 mm below
the edges of the maxillary teeth when the patient pronounces the letter (S). (Fig. 10-b)
Again, the relationship between maxillary and mandibular incisors should be
positioned in a way that fulfills esthetics, phonetics and function incisal guidance,
should be restored in order to restore the normal function of the anterior segment.

5. Facial relationships and proportions:

Mid-Line:
The facial and incisal midlines should coincide as much as possible. (Fig. 11)

Fig. (11): Mid-Line is bisecting the face

into two equal halves.

a) Symmetry:

The observer expects the left and right sides of the mouth to match. A balanced
arrangement imparts harmony and symmetry. Perfect horizontal symmetry occurs
when all anterior teeth have the same shape.

Dentists prefer more irregularities than do patients, because variety in arrangement

and shape produces a more natural appearance. However, this concept should be
discussed with the patients during treatment planning.

b) Golden Ratio:

Proportion implies arithmetic and geometry. Early on beauty was associated with
numerical values and a harmony of proportions.
 Maxillary central incisors are positioned at the middle of the smile, making
them the most prominent teeth. They have the widest crowns among
anterior teeth.
Chapter 2 Esthetic Considerations in Dental Restorations

 Canines are the next widest and lateral incisors are the narrowest. However,
from a frontal view the apparent sizes of teeth should become progressively
smaller from the midline distally by a ratio of 0.618.
 For objects to be proportional the ratio of 1: 1.618 has been determined to
be esthetically pleasing

Golden Proportion
Fig (12)

The Golden ratio (1.618 to 1.0) has been calibrated as the standard
of visual esthetics since ancient times.

Factors influencing the Esthetics of Dental Restorations

Thus we conclude that many factors have a great influence on the final result of
dental restoration esthetics. These factors vary in their degree of influence. Among
these factors:

1. Age of the patient:

In case of young females, incisal display is twice that of a male. However, with
age the length of exposed maxillary incisors id decreased and more mandibular
incisors is exposed.
Make small facets especially in old patients. Also, artificial crack lines and areas
of high chroma give a more natural look in old ages.

Young teeth Old teeth

1. Lighter in color (Higher value) Darker in color (Lower value)
2. Lower color saturation (Lower chroma) Higher color saturation (Higher chroma)
4. . More textured surfaces Less textured surfaces,smoother
5. Higher epithelial attachment level Lower epithelial attachment level, longer
teeth
6. Significant incisal embrasures Less significant incisal embrasures
7. Smaller gingival embrasures Larger gingival embrasures
Chapter 2 Esthetic Considerations in Dental Restorations

8. Incisal edges of lateral incisors are shorter Anterior teeth have the same level due to
than central incisors and canines attrition.

9. Have lighter characterization Have marked characterization

2. Sex of the patient:

Feminine teeth Masculine teeth

1. More rounded line and point angles More angular
2. More pronounced incisal embrasures Incisal embrasures are more squared and
not pronounced as feminine teeth
3. More translucent incisal edges with Stronger characterizations with dark craze
some hypo-plastic striations gives lines, specially with older ages
illusion of delicacy

3. Dimension of incisal embrasure get progressively wider and deeper from

central incisors to first premolar. (Fig 13)

(Fig 13)

4. Individual tooth size and position. (Arrangement: Balance, Symmetry

proportion)

5. Vertical dimension and inter-arch space.

6. Relationship of anterior teeth to upper & lower lip.( Lip & smile Line)

7. Variations in the level of the gingival line. ( Gingival Line)

8. Tooth color & shape variation.

 Incisal edges of central incisors and canines cusp tips should lie on the same
curved line (Smile Line) while lateral incisors should by about 1.0mm
shorter.
 Incisal embrasures between anterior teeth should be opened specially those
between lateral incisor and canines.
 Mirror image is artificial Slight irregularities between right and left incisors
should be made to avoid mirror image.
 Round distal corners of incisors.

9. Patient needs and expectations have to be met.

 Chapter 2 Esthetic Considerations in Dental Restorations

Guidelines during clinical procedures which may influence the Esthetic

Outcome of Dental Restorations:

Many steps even before the restoration fabrication can influence the final outcome
of dental restoration esthetics.
I. Soft tissue management.
II. Tooth reduction.
III. Shade matching.
IV. Color variation.
V. Surface characterization.
VI. Degree of gloss.
VII. Tooth form ,size and arch position

I. Soft Tissue Management:

1. F.L. Formation.
2. Retraction cord & tissue displacement procedure.
3. Impression Technique.
4. Temporary restoration.

All the above steps should be done with the least possible trauma in order to
preserve the heath, color and texture of the gingiva.
Soft tissue response towards the temporary or permanent restoration is greatly
affected by their smoothness (finishing) and plaque adherence.

II. Tooth Reduction:

Insufficient tooth reduction affects esthetics. To develop proper color a minimum

of 1-1.5mm thickness of ceramic is required. Insufficient bulk results in lack of
color vitality or overcontouring in the final restoration which in turn affects the
gingival health.

Two areas that need special attention are

Labioincisal→ Caused by one plane reduction.
Cervical → Shoulder F.L. provides adequate ceramic bulk to reproduce correct
color. Many clinicians overlook this and as a result there is either an opaque color
appearing or overcontouring at the neck of the tooth compromising esthetics.
 Chapter 2 Esthetic Considerations in Dental Restorations

III. Shade matching:

1. Incorrect shade selection.

2. Insufficient reduction whether localized in certain areas or involving all the
facial surface.
3. Thick metal framework & thick opaque with insufficient ceramic (dentine &
enamel) to reproduce translucency.

IV. Color of Human Teeth & Color variation:

Natural tooth color depends on the composition, structure and thickness of dental
tissues. The dentist should have some basic knowledge:

A. The main dental tissues are enamel, dentine and pulp. Teeth are usually in the
yellowish-white range.
 Pulp: is in the centre and its volume diminishes with age decreasing its
influence.
 Dentine: surrounds the pulp and is the most important factor in color
determination. It is relatively opaque. As age develops, dentinal changes
occur producing color changes.
 Enamel: color depends on its composition, thickness, opalescence and
surface texture. It is translucent.
 Young teeth have thick enamel with low mineral content, resulting in
translucency and high value.
 Older teeth are more mineralized and become thinner due to wear thus
pronouncing translucency to the point of transparency which pronounces the
color of underlying dentine.

B. Areas within the same tooth;

 Incisal third: enamel is predominant reaching 1.5mm.(bluish & translucent)
 Middle third: enamel thins out and the tooth becomes less translucent.
 Cervical third: Thin enamel .3mm almost transparent so the color of
underlying dentine is predominant.
 Chapter 2 Esthetic Considerations in Dental Restorations

C. Teeth in general:

1. Canines are the most intensely pigmented teeth while laterals show the least
pigmentation due to the thickness of dentine.

2. The greatest pigmentation within the tooth is found cervically.

3. Translucency is most apparent in the incisal edge, cusp tips and proximal
surfaces where there is only enamel and no dentine.

4. Translucency suggests vitality of the tooth.( life-like appearance)

5. Teeth exhibit different colors in different zones and color selection for each
zone should be recorded separately.

V. Surface Characterization.

Surface texture greatly affects light transmission and should be carefully

transmitted to the technician to be developed in the ceramic restoration for
faithful color reproduction.

VI. Degree of Gloss:

Amount of surface gloss affects the reflection of light & along with surface texture
enhances the natural appearance of a restoration.

VII. Tooth form, size and arch position.

Restoration of a single missing maxillary incisor can be quite challenging.

Exact duplication of the adjacent tooth is mandatory. It should be a mirror image
concerning the outline, shape, size and form of its counterpart.

Outline Form: The mesial, distal and incisal angles should be faithfully copied in
the restoration.
Size: same size space = same position of line angles.
Incisal Embrassure = same size and location.
Chapter 2 Esthetic Considerations in Dental Restorations

Illusion and Perceived Size: (Principle of line)

Line angles affect the size. If the edentulous space is

smaller or larger than the space previously occupied
by the tooth we may use optical illusions to overcome
this problem.

To create an illusion of:

 Smaller size: place the mesiofacial and distofacial line angles closer together.
 Larger size: move the proximal line angles farther apart.
 Greater crown length: place vertical developmental grooves.
 Shorter crown length: If the crown is too long, to make it appear shorter
create a cementoenamel junction, simulate a root portion or add pink ceramic to
simulate the gingiva.

Examples Of Esthetic Restoration Failure

1. Color monotony: the tooth appears as if it is made of dentine only.

2. Lack of translucency: this is mostly common with metal ceramic

restorations due to the fact that metal framework blocks out the light
transmission causing dead, dull or opaque artificial coloring effect.

3. Artificial teeth arrangement: too uniform arrangement of teeth gives an

artificial look, while natural built-in irregularities give more natural look.

4. Poor soft tissue restoration relationship.

5. Lack of symmetry & harmony. Restorations should copy the form & color
of neighboring teeth.