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 recognize the fresh ideas of present-day pioneers who are embracing the latest cosmetic procedures and the patients’ demand for a natural look. The fundamental principle of cosmetic dentistry is the achievement of dento-facial 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 recognize 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
Figures 1a and 1b. Comparing the position of the smile line in relation to the surrounding elements (buccal corridors, lips, and gingival line) in natural dentition (a) and restored dentition (b).
This technique has lost its original purpose and is so marginalized 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into account and a new classification system introduced.2 If this doesn’t occur, then the current trend will lead to an outdated “uniform dentition.”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, dento-facial 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 problems3 (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 conserv-ative 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 dento-facial 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 utilized.3
Position of the Gingival Line
Figure 2. The frame around the dentition is often observed in a natural-looking, pleasant smile.
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 cor-ridors so that they remain and are not filled completely. These natural spaces are re-quired to complete the frame and ensure that the dentition stays within the correct proportion in the mouth (Figure 2).
Clear Gaps, Clear Steps (Interincisal)
Figure 3. Very often natural irregularity creates gaps and spaces, which make a smile attractive.
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 attractive1 (Figure 3).
Hills and Valleys
Figure 4. (A) highest point=buccal; (B) mid tone; (C) lowest point=proximal.
Buccal surfaces should be shaped so that 3 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 color 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 dento-facial harmony6 (Figures 4 to 6d).
Figures 5a to 5d. The incidence of light reflection on a surface tends to produce an optical expansion of this surface. This phenomenon has been used (and is shown above) in order to increase tooth width.
Figures 6a to 6d. The incidence of light reflection on a surface tends to produce an optical reduction of this surface. This phenomenon has been used (and is shown above) in order to reduce tooth width.
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 outdat-ed current principles. To achieve dento-facial harmony, an “individual natural look” must have the maximum impact in terms of dental excellence.
- Rufenacht CR. Principals of Esthetic Integration. Chicago, IL: Quintessence; 2000:71-72.
- Molavi D. The role of fashion in aesthetic dentistry. Dent Today. Feb 2005;24:86-90.
- Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
- Petren T, Carlsoo S. Anatomi. Salköping, Sweden: Gummessons; 1983: 174, 15.
- Rosenthal L. The smile lift: a new concept in aesthetic care, part 1. Dent Today. April 1994;13:66-71.
- Rufenacht CR. Principals of Esthetic Integration. Chicago, IL: Quintessence; 2000:82.
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.