Focus On: Prosthodontics



Joseph J. Massad, DDS

Joseph J. Massad, DDS, explains how to achieve patients’ perception of what they want their final smile to look like at the end of treatment.

Q: How can a patient accept the final aesthetic tooth display before treatment?

A: The answer begins at the assessment and ex­am­i­na­tion appointment. After a series of patient questions are concluded, it becomes very clear what the patient likes and does not like about his or her existing smile. At this point, it becomes incumbent that the clinician addresses these concerns with the patient before attempting to quote a fee and, for that matter, beginning any treatment other than making preliminary facial photos and diagnostic casts.

Anticipate rejection and then intercept it by allowing your patients to preview their final smile display by deciding themselves in vivo at the chair (Figure 1).


With the use of an aesthetic application called the facial analysis, the practitioner is directed to take a series of photos at the time of the initial patient ap­pointment to qualify the appearance and condition of the patient’s facial features, as they exist before any treatment is initiated. The 5 required photos are described as follows:

1. Frontal face showing the lips and teeth open at rest. There should be no contact of teeth or lips, and there should be at least 5 mm of opening between teeth and lips.

2. Frontal face with teeth and lips touching.

3. Frontal face with a full smile.

4. Face profile at rest with at least a 5-mm space between teeth and lips.

5. Face profile with teeth and lips touching.

The photos will automatically inset into the program in a specific location with various examples of the 5 facial positions with multiple examples of various facial presentations normal to all people. The patients are then asked to compare their photo with one of the examples to see which closely identifies their facial features. From this point forward, the practitioner can qualify the areas that can and cannot be altered with dental procedures. Such recommendations are facial lifts, facial fillers, lip implants, removable implant-retained prostheses versus fixed implant prostheses, etc.

Figures 3a and 3b. Tooth shells (a) and the female patient’s try-in (b).

Patients need to be aware that “beauty is in the eye of the beholder.” It is normal for the midline of the teeth to be to the left or to the right. Lip pulls and asymmetry are also natural. The vermilion border of lips can appear in different degrees of fullness and so on. Now, this does not mean that we are not going to beautify our patients; however, it allows us to avoid getting trapped in aesthetic areas that we cannot control (Figure 2).

Once we have identified that our patient has certain normal facial asymmetrical features, we can now let the him or her see a preview of our proposed aesthetic tooth display by using very thin dental tooth shells that can be placed over the patient’s denture prosthesis or, in many cases, over the natural dentition. This is done to view the incisal tooth display (both at rest and when smiling) while identifying the midline, lip pull, and the amount of tooth and gingival showing. These tooth shells are thermoplastic, allowing for easy adaption to most configurations, and they come in 4 molds and 3 sizes (Figure 3).

Figures 2a to 2c. Lip pull in male patient (a), lip pull in female patient (b), and midline in male patient (c).

The point is that we must communicate with our patients to be able to give them the best dentistry possible, while understanding that what they perceive, as to what they want to look like, may not always be what we can fabricate for them in our finished prosthesis. I hope that the advice presented herein will assist your quest for providing a platform to communicate better with your patients.

Dr. Massad owns a private practice in Tulsa, Okla. He holds faculty positions at Tufts University School of Dental Medicine in the department of comprehensive dentistry and at Uni­ver­sity of Texas Health Science Center Dental School in the de­part­ment of prosthodontics. He previously held a faculty position at the Oklahoma State University College of Osteo­path­ic Medicine and was past director of removable prosthodontics at the Scottsdale Center for Dentistry. He served from 1992 to 2003 as an associate faculty member at the Pankey In­stitute. He is a Fellow of the both the American and In­ter­national Colleges of Dentists, a Fellow/Regent of the Inter­national Academy for Dental Facial Esthetics, and an Honorary Member in the American College of Prosthodontics. He can be reached at

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