A review of cosmetic dentistry in the last decade clearly demonstrates that emphasis has been placed on dentists’ technical skills at the expense of (creating) a natural look. As a result, a ‘manufactured look’ has become the signature of today’s cosmetic dentistry.
Testimony to this can be seen in our daily lives. Why should we seek change if this ‘manufactured look’ is supposedly popular with patients? The answer, quite simply, is this: we need to recognise the fresh ideas of present-day pioneers who are embracing the latest cosmetic procedures and the patient’s demand for a natural look.
The fundamental principle of cosmetic dentistry is the achievement of dentofacial harmony. A natural-looking dentition should be the ultimate target for the result of cosmetic restoration.
This article focuses on current practice and the failure to recognise the potential of modern techniques. Today, the most common technique used to achieve a prominent smile is enlargement of the dentition — a thickening and lengthening of the teeth; the natural gaps and spaces are often eliminated and glossed over.
The new dentition is no longer in correct proportion with the full line of the mouth corners (lateral corridors). This causes destruction of the natural anatomical position of the smile line in relation to the surrounding elements (buccal corridors, cheeks, lips and gingival line). (1)
This technique has lost its original purpose and is so marginalised that it has become the paradigm of the fundamental problem now facing cosmetic dentistry. To combat this, general, individual and cultural factors must be taken into account and a new classification system introduced. (2)
If this doesn’t occur, then the current trend will lead to an outdated ‘uniform dentition’. As a result, dentofacial harmony will not be achieved. This will have a different impact on patients’ appearance depending upon the age of the patient, thus creating a number of problems (Figures 1a and 1b).
In younger patients lengthening of the teeth requires elevation of the gingival margin and extension of the incisal embrasures vertically. This, combined with thickening buccally, results in stretching of the labial muscles to a certain degree in the rest position. (4)
Limited muscle contraction ability can lead to the following problems:
A reduction of muscle flexibility may occur as the muscles are already stretched to a certain degree in the rest position. As a result only a slight difference among the rest position, natural smile and retracted smile occurs. Hence, in a retracted smile the patient will over-stretch the muscles; consequently the smile may appear false and frozen and a reduced number of teeth are seen. A youthful appearance may change into a more mature, old-fashioned and conservative look, which can be very significant in younger patients.
In older patients, enlarging the dentition in order to support the labial and facial muscles that have lost their firmness and flexibility occurs with a dental ‘face-lift’. (5)
The affected muscles are pushed away by the enlarged dentition, consequently displaying an over-exaggerated presence of teeth, producing a very pronounced dentition and unnatural look. In order to reduce the need for enlarging the dentition, the following techniques should be considered to ensure that particular dentofacial elements become more prominent and to avoid an overcrowded look.
A frame around the dentition is often observed in natural-looking, pleasant smiles. This frame is necessary to create a prominent smile. To be able to create this frame the patient’s natural anatomical form should be utilised.
Position of the gingival line
The gingival line should remain visible in retracted smile, as this line creates the superior line of the frame. In cases of crowded teeth or a gummy smile, it may be necessary to enhance the gingival margin, but care should be taken to avoid eliminating the gingival line from the smile. (3)
The objective is to create a superior gingival line, not a superior lip line (Figure 2).
The length of the maxillary teeth in relation to the lower lip should be such that the incisal edges (incisal embrasures) are visible in retracted smile position. The objective is to show incisal definition and create an inferior incisal line, not an inferior lip line. The incisal embrasures form the lower part of the frame (Figure 2).
When designing molars and premolars, attention should be paid to the buccal corridors so that they remain and are not filled completely. These natural spaces are required to complete the frame and ensure that the dentition stays within the correct proportion in the mouth (Figure 2).
Clear gaps, clear steps (interincisal)
Producing emphatic gaps interincisally and creating different levels in incisal embrasures will make the teeth look longer and add definition to the smile line. This technique may be successfully employed in cases with poor and unsuitable spacing where lengthening of the dentition is required. Very often, natural irregularity creates gaps and spaces, which make a smile attractive.
Hills and valleys (buccal, proximal)
Buccal surfaces should be shaped so that three different levels can be observed, the highest point being that of the buccal region and the lowest point the proximal. The highest point of the buccal reflects light and is followed by the middle area, which automatically appears less light, as does the lowest point of the proximal. The contrast of colour creates dimension and ultimately produces an optical illusion due to the establishment of differing levels. This technique is particularly valuable where thickening of the dentition interferes with the patient’s dentofacial harmony.
Cosmetic dentistry must consider the new ‘manufactured look’ with its ‘uniform dentition’ as the result of a technical failure. This threatens to destroy and disconnect the natural beauty around it. The concept of ‘fashion in aesthetic dentistry’ is based on strong, practical examples, illustration and cogent arguments questioning many outdated current principles. To achieve dentofacial harmony, an ‘individual natural look’ must have the maximum impact in terms of dental excellence.
The author would like to thank Gabriel Clarke (TV journalist), Brian Barfoot (designer), Louise Clark (editor), James Reid (technician) and Drs Ken Hamlett, Ramón Badalbit and Julian Webber.
1. Rufenacht CR (2000). Principals of Esthetic Integration. Chicago, IL: Quintessence 71-72
2. Molavi D (2005). The role of fashion in aesthetic dentistry. Dent Today. Feb; 24:86-90
3. Morley J, Eubank J (2001). Macro esthetic elements of smile design. J Am Dent Assoc. 132:39-45
4. Petren T, Carlsoo S (1983). Anatomi.Salköping,Sweden:
Gummessons 174, 15
5. Rosenthal L (1994). The smile lift :a new concept in aesthetic care, part 1. Dent Today. April 13:66-71
6. Rufenacht CR (2000). Principals of Esthetic Integration. Chicago, IL: Quintessence 82
Donna Molavi will be speaking at the World Aesthetic Congress 2008 to be held on 6 and 7 June 2008 at the QEII Conference Centre, London. For further information please call Independent Seminars on 0800 371652 or visit www.independentseminars.com