Written by Stephen D. Killian, CDT Wednesday, 31 May 2006 19:00
In your dental practice and in our laboratory, we are all being asked to create aesthetic smile makeovers. Many dentists are working to build the fee-for-service and cosmetic sides of their practices. I am often asked to finalize cosmetic restorations with nothing more than a preoperative study cast and a few boxes checked on the work order form. The chances of achieving complete cosmetic success by anyones standard is a matter of luck, even in the hands of the most talented professionals.
Today, with modern digital photography, it has never been easier to communicate the desired result to your laboratory technician. I am being asked more and more which poses or views I find most useful for determining the most natural and aesthetic restorative result.
When beginning a full mouth of restorations or a cosmetic veneer case, the dentist and technician must understand and practice basic occlusal and aesthetic principles. It is essential to plan for a lasting result, and therefore verification of centric relation at maximum intercuspation/centric occlusion is the primary starting point. Insuring your patients restorations for lasting function and aesthetics can only be achieved (in my experience) through a stable bite. In 33 years of dental lab experience, the greatest longevity of my restorations occurs within mouths in which the condyles are in the uppermost position simultaneously with the teeth at maximum intercuspation, with even pressure on all teeth, with functioning anterior guidance, and no functioning or balancing interferences on the inclines of posteriors. To plan a case in which we do not equilibrate or restore into centric relation is a plan for failure. A balanced and stable bite is all the insurance we need for creating lasting restorations.
The second step, and the main focus of this article, is the process of obtaining photographs needed to help convey all anatomical aspects of the desired finished restorations, such as incisal length, tooth form, incisal edge position (overjet and overbite), occlusal plane (Curve of Spee), labial inclination of anteriors, the buccal corridor (buccal bulk of posteriors), gingival height of contour, and incisal and gingival embrasure contours. To ensure an accurate photographic record of the patients anatomy, each of the 5 photos shown in this article must be taken without lip retraction or anesthesia. Third, a set of accurate and neat preoperative models is mounted on a semiadjustable articulator using a face-bow transfer. These models will be duplicated at the lab, refined to presentation quality, and readied for the diagnostic wax-up. Lastly, a set of comprehensive written instructions are created from the doctor/technician consultation, designed to communicate clearly both the patients and the dentists expectations. When we have hit all 4 of these marks, we have never missed in the process of creating lasting excellence in dentistry.
Figure 1. Full-face, say "eee" pose.
This shows the patient's full face while saying "eee". Notice that the lips are in a fully exaggerated, "say cheese"-type smile. The teeth are slightly apart, making the lower incisal edges clearly visible. All of the features of the face are visible in order to align the vertical midline and the horizontal occlusal plane. I can't emphasize enough how important this single photograph is. All that we need to know about the patients face in relation to her teeth is recorded here. The eyes at the pupils and lips at the corners dominate almost everyones horizontal features, and so naturally the horizontal occlusal plane must be parallel to them both. The vertical plane is 90? to the horizontal plane that we determine from the eyes and lips.
I have observed that most noses are, at the very least, slightly off-center from the vertical midline and can be angled oddly toward the right foot or the left foot. Because of this crookedness, noses don't make a reliable feature on which to base the position and angle of the vertical midline or the horizontal occlusal plane. Oftentimes, faces are asymmetrical. One eye is lower than the other or one corner of the lips is lower than the other. The lines drawn between the pupils and the corners of the lips are not parallel. In such cases we must split the difference between these 2 lines in order to create a balanced and pleasing angle for the horizontal occlusal plane. The nose should only be considered as a less important feature and therefore should be considered last when creating a balance with the teeth in relation to the face.
As an afterthought, the chin should receive virtually no consideration as an influencing feature. Noses and chins are more rounded and lack the call to attention that the eyes and lips possess. Consider also that the nose and chin change their appearance with respect to symmetry and angle with even the slightest variation from a straight-on view. In other words, we are used to seeing an asymmetrical view of the chin and nose because we seldom view faces straight on, so much so that when we see a face straight on we tend to ignore the asymmetry of the nose and chin. We turn our focus to the eyes, lips, and teeth instead.
To sum it up, the eyes and the lips have it. Be certain that you capture this exact pose in crisp focus and proper exposure.
Figure 2. Closeup "eee" pose.
This is a closeup of the same facial pose as Figure 1, showing no more and no less than the corners of the lips. This photo, along with the study models, helps determine whether changes are needed to existing anatomical features such as midline position and angle, incisal length, Curve of Spee, the gingival and incisal embrasure contours, and the buccal corridor. For the record, I find it to be much faster to shoot this second photograph rather than to use software to zoom in and crop the mouth from Figure 1. Cropping a photo with your software is often a poor substitute for a crisp closeup shot.
Viewing Figures 1 and 2 together brings the teeth into closeup perspective with the face. Now we can bring close focus to the exact angles of the midline and the horizontal occlusal plane. From this closeup shot we can now begin to focus on differences from our ideal plan and consider conforming with or consider variations away from length-to-width golden proportions for the maxillary anteriors. We can focus on plans to idealize the gingival embrasures and the scalloping of the papillae in the maxillary anteriors. Do we want a younger look with open incisal embrasures or a more masculine look with square, closed incisal embrasures?
Sometimes teeth are so malformed or broken down that they provide little direction for determining the ideal. In such cases smile style catalogs, model smiles from magazines, and old full- face photographs of the patients young teeth can all help in determining the ideal result. Something else that has become more important to many patients is the elimination of the dark space along the buccal corridor. This is sometimes forgotten during doctor-patient consultations, but it becomes an issue after the restorations are delivered. We should always consider the possibility of bulking out the buccal surfaces of the maxillary posteriors in order to present more white tooth structure in the buccal corridor. Frame this pose carefully, then be certain of crisp focus with the proper exposure. Keep the same magnification and exposure settings for all 4 of the closeup shots.
|Figure 3. Relaxed smile pose.|
In the relaxed smile pose, ideally the upper lip aligns with the gingival height of the upper anterior teeth. Also, the curve of the lower lip aligns with the upper anterior incisal edges and the buccal cusp tips of the posteriors. This pose isn't much different from our first closeup shot in Figure 2. What we have done here is take the lower anteriors out of the picture and replace them with the lower lip. Our goal is to use the upper and lower lips as a frame to help determine the ideal gingival height and the ideal incisal length for the maxillary anteriors. A curve drawn along the incisal edges should follow closely along the natural curve of the lower lip. The buccal cusp tips should also follow closely along the curve of the lower lip. From anterior incisal edges to posterior cusp tips, the lower lip also shapes the frame for the Curve of Spee. When posterior cusp tips fall below the corners of the lips, it becomes obvious that the ideal has not been achieved. Conversely, if the Curve of Spee is too drastic and the posterior cusp tips fall well above the corners of the lips, then the buccal corridor can look too dark and too void of white tooth structure. Don't forget to capture this shot as before, just to the corners of the lips and no more. Focus sharply and expose correctly.
Figure 4. Relaxed smile side view pose.
This is the same relaxed smile pose as in Figure 3 but taken from the side at a 75-degree angle to the sagittal plane. Check the labial contour and inclination as well as incisal edge position. Ideally, the incisal edges will just touch the dry side of the wet-dry inner vermillion border of the lower lip. Seventy-five degrees is a general angle meant to communicate the need to see tooth No. 9 ahead of tooth No. 8 and not blocked from view by tooth No. 8. The idea is to see one of the central incisors in perfect side profile as it emerges from the maxilla in relation to the occlusal plane. In this photo tooth No. 9 is seen slightly ahead of tooth No. 8 and in side profile.
We must also see the incisal edges and cusp tips unobstructed in order to determine clearly the angle of the occlusal plane. The corner of the lips also must be in the photo to help visualize the occlusal plane. The most pleasing angle of the facial surface of the centrals to the occlusal plane is about 90?. Don't deviate from that angle more or less than about 10?. Of course, function is a large consideration as well. If changes to the original incisal edge position are to be considered, then provisionalization would be the proper course to verify that the patient can form proper F sounds (say fifty-five). The F pose is similar, but all edges and cusps are sunken into the wet side of the wet-dry inner vermillion, obscuring their view for occlusal plane determination but verifying the F position. You may want to photograph this F position as a supplemental and sixth shot. Take time to frame this correctly. Keep the same exposure setting as before. Focus and shoot.
|Figure 5. Open relaxed smile pose.|
This is also a relaxed smile pose but with the mandible opened just enough to allow viewing of the lower incisal edges unobscured by the upper incisal edges. Make sure you can see the lower teeth 0.5 to 1.5 mm above and aligned with the curve of the lower lip. This is a less critical photo, but no less important if we are considering an absolute ideal length for the lower incisors. Keep in mind that the length of the lower incisors can be changed by altering the labial or lingual angle. Angling the lower incisors labially can shorten the space against the lingual surface of the upper anteriors. Angling the lower incisors lingually can create more space for lengthening the lower incisors. The length of the lower anteriors can also be determined by increasing or decreasing contour at the lingual surfaces of upper anteriors.
Keep in mind that changes in the labial position of lower anteriors will affect lower lip support. If changes are to be considered, then provisionalization is the proper course to check their effect on lower lip support, F sounds, S, T, and D sounds (tip of the tongue to the cingulum of the upper incisors), and envelope of function. Check the exposure setting. Frame carefully, focus sharply, and shoot.
Now that we have our 5 (or 6) photos, lets assume that our patient is far less ideal and is aesthetically challenged. We will use my model as an approximation of the place at which we want to arrive. All of us could use a map when we want to travel to our destination over the shortest distance. Granted, a map of Manhattan won't get us to the Golden Gate Bridge, so break out the smile catalogs, the magazine model smiles, and photos of the patients young teeth. Every mouth is different, and so will be the ideal result, but it is the difference between the unrestored mouth and the pre-planned ideal mouth that will tell us how far we have to go.
The preoperative photographs discussed here give us all the information we need to start. When we combine these photographs with our knowledge and experience together with the patients desired outcome, the dentist and technician can arrive at a truly excellent result.
Suggested Study and Continuing Education:
Cranham JC. Records for Success: Part 1 [DVD on digital photography]. www.cranhamdentalseminars.com; Telephone: 757-465-8900.
Continuing education in comprehensive dentistry, occlusion, and cosmetic dentistry. Peter E. Dawson, DDS; Dawson Center for the Advancement of Dentistry; St Petersburg, Florida; www.dawsoncenter.com; Telephone: 800-952-2178.
Continuing education in comprehensive dentistry, occlusion, and cosmetic dentistry. Frank Spear, DDS, MSD. Seattle Institute for Advanced Dental Education; Seattle, Washington; www.seattleinstitute.com; Telephone: 888-575-0370.
Doctor and patient education on occlusion. BiteFX: Unveiling Occlusion [CD, DVD]. 3D animations to help explain occlusion to the patient while gaining acceptance for the treatment plan. D2Effects and Dynamic Thought (Donald N. Reid, DDS; Douglas A. Brown, MA); www.bitefx.com; Telephone: 877-224-8339.
Dental application digital cameras, printers, mirrors, etc. PhotoMed International; Van Nuys, Calif; www.photomed.net; Telephone: 800-998-7765.
Smile Guide flipchart catalog; in office and laboratory versions. Discus Dental; Culver City, Calif; www.discusdental.com; Telephone: 800-422-9448.
The Smile Catalog flipchart catalog. A patient and laboratory communication guide for the esthetic dentist. Las Vegas Institute; Las Vegas, Nev; www.lvilive.com; Telephone: 888-584-3237.
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