The question of what makes something ‘aesthetic’ or pleasing to the eye is one that often plagues dentists. We are so concerned with our patients’ perceptions of beauty that it is always on our mind.

The sense of aesthetics is an innate quality that we all carry. This sensibility is intertwined with our own internal creativity and curiosity, as well as our desire to create. Many people conflate a particular affinity for aesthetics with a lesser ability in other more technical areas, but in reality these are not mutually exclusive.

As dentists, we balance the technical and the aesthetic every single day. It can be challenging to handle the needs of both these areas in concert.

A Pankey Take on Aesthetics

Dr. Pankey had a particularly eloquent way of describing aesthetics. He clearly had a great appreciation of the world. This is why he combined his appreciation for aesthetics with the needs of dentistry, which resulted in multiple insights about the complexities of aesthetic dentistry.

Dr. Pankey’s aim was to learn the ins and outs of dental aesthetics to maximize quality of patient care. He had a vision of organizing all of the information he had acquired and making it available to more dentists.

The S Curve

An important tenant of dental aesthetics is the ‘S’ shaped curve that visually stimulates a sense of beauty. This has to do with the way it moves the eye and creates a flowing movement. The curve is a common aesthetic aspect of teeth and tissue, especially in the tips of every papilla to the zenith point.

We see the S shape as a result of the emergence profile or the angle of the entrant line of each tooth. Contour also plays a role in this specific part of the smile’s appearance. All in all, it’s important to pay attention to this aesthetic nuance in your work.

What do you think is the most important consideration for aesthetics in dentistry? 

Every patient has a story that makes their case unique. When we embrace their path to treatment and make an effort to understand their motivations, we can provide even more excellent care.

A great example of this simple lesson came in the form of my patient Anne. I knew Anne well, as she ‘grew up’ in our practice and had been a regular patient for many years. This fact added an unexpectedly challenging element to her case. I knew I needed to re-familiarize myself with her interests and background instead of taking our past relationship for granted.

Restorative Case For a Future Hygienist

Anne is nineteen and currently training to become a dental hygienist. Her personal dental experiences spurred her interest in the field. She’s excited to provide patient care that improves both oral health and self-image.

All of these details about Anne informed how I approached her treatment. Her primary esthetic concerns were a peg lateral #7 and a congenitally missing #10. She also had canted axial alignment, mottled enamel, and uneven gingival zeniths with a high smile line.

We decided on comprehensive restorative treatment approach that would correct these problems and provide her with a result she could readily show off. The treatment consisted of orthodontics, an implant for #10, and periodontal surgery to reposition gingival levels. We also moved ahead with occlusal equilibration and a diagnostic wax up.

To round out the case, we did tissue sculpting on #10 in addition to esthetic/functional testing and refinement via provisionals. Anne got beautiful e.max veneers on #5, 6, 7, 8, 9, 11 and 12. Finally, she got an implant supported e.max crown on #10.

Matt Roberts CDT handled the lab side of Anne’s case and did a stellar job. She can now go forth confidently into her career and help others embrace treatment that can change their lives.

What case put a smile on your face recently? We’d love to hear what you think in the comments! 

When Dr. Richard Green read Dr. Lee Ann Brady’s blogs on pitch and bevels, he decided to jump in with a thoughtful response. Read on for more discussion of this fascinating topic.

Crossover and Movement: Consider the Edges

I loved Dr. Brady’s article concerning edges (pitch and both bevels) and the conversation about natural teeth, composition, and porcelain. I was reminded of some of my learning with and from Henry Tanner while refining my occlusion in the mid-70s. It worked for me no matter what material and bite splints were used.

Henry was the first to introduce me to ‘crossover.’ At the time, one of the anterior teeth you did not talk about were the cuspids. They too have important facets (pitch and two bevels) that need to match cusp tip to cusp tip, regardless of the material.

When moving into crossover and the cuspid tips touch, if the pitch facet does not match or is pointed, sloped, or rounded, you often see the masseter or temporalysis muscle twitch. This occurs as the patient hesitates in their movement. That smooth transition back to the incisal edges of the centrals and laterals is important.

I also realized during my career that certain patients (teens, golfers, baseball players) would often stabilize their head while their teeth were cuspid tip to tip or in a crossover position at the point of their impact with the ball.

Improvements can be accomplished by simply taking the flat portion of a ½ J (wheel fine diamond) and creating matching facets on upper and lower cuspids. Polish them and both the leading and trailing bevels so that the movement becomes smooth. If the patient wants to stop cusp tip to cusp tip on the upper and lower cuspid, there is a stable stop and the muscles are comfortable.

To be continued…

Dive into this case for a look at Dr. Owen’s thought process and treatment protocol leading to porcelain restorations. 

Angela was 27 when she came to us asking about options to improve her smile. She was getting married within a year. She hated the appearance of the bridge #3-6 that had been placed in high school. It was repaired at the buccal margin of #6 the day of delivery. She also said she wanted to avoid implants because of time issues and she didn’t want more crowns.

Patient Background

Angela was congenitally missing #4, 7, 10, 12, 13, 20, and 29. In the past, she had implants to replace the lower bicuspids and said the process took too long. Her previous dentist had placed two upper bridges – #3-7 with pontics on #4 and #7 and #14-10 with pontics on #13 and #10. The space for #12 did not exist.

Treatment Plan

I noticed her narrow central incisors compared to her laterals and the general contour and color of the bridges. I knew we could improve her smile with all porcelain restorations. Implants to replace missing teeth and veneers on the centrals would make a difference. We did a wax up that she took home to study, comparing it to the model of her existing restorations. She visited the periodontist who would do the implants and I showed her lots of photos of other cases similar to hers.

Creating Porcelain Restorations

Ultimately Angela agreed with our plan. She had implants replacing #7, 10, and 13. We used Zirconia abutments and e.max crowns, as well as an e.max crown for #14. She opted for a Zirconia bridge #3-5. While she was healing, we made provisional bridges, including the cantilevers for the laterals. She was hesitant about the veneers on #8 and #9, but before we began I removed the bridges and created a trial restoration with the wider veneers and proper bridge contours. I took photos and let her think about it before she agreed. She got married with a beautiful new smile.   

What interesting cases are you currently working on? 

Do you feel reticent about having someone other than you use the facebow? 

A Spatial Reference Point Story

Recently over the holidays as I was “channel surfing” I came across the movie Apollo 13. This is one of those movies that no matter how many times I have watched it, I just have to stop and watch it one more time. Every time I do, I can’t help but get misty-eyed when it gets to the part when the crew make it back to Earth safely (SPOILER ALERT … But you probably read this in the history books anyway).

For me, there is one super exciting moment in the film when Astronaut James Lovell (aka Tom Hanks) has to find a reference point to correct their descent back to Earth from space or burn up on re-entry. Since he cannot use his on-board computers, he lines up his spaceship with the Earth in his window.

“Keep the Earth in the window!” A spatial reference point! Too much correction and their spaceship burns up on re-entry. Too little and they skip off the Earth’s atmosphere.

Make Your Facebow Process Simpler

In our dental offices, the facebow is used to give us a spatial reference point for mounting diagnostic or working models of our patient’s dentition. This is done onto an articulator that approximates the realities of our patient. Sure, you might be able to mount casts arbitrarily, but is your accuracy reproducible? The facebow is a simple tool in our armamentarium to make our life easier.

The question remains, “Is this a task that the dentist must perform?” In my office when we create exquisite dental mountings, I delegate this task to my awesome dental assistants.  With a little training they can do this immediately and the procedure only takes a few minutes.

This involvement is a great way for them to demonstrate their knowledge. It paves the way for more opportunities to open conversations about the Dentist’s Care, Skill, and Judgement. They become your chairside cheerleader and highlight your expertise. They will also express how a critical bite registration record or protrusive record performed by the dentist will only enhance the outcome of treatment.  

Information gathered through the use of a facebow makes our dentistry more predictable. It distinguishes you and your team as a highly trained dental practice.

Don’t burn up on re-entry or skip off into space. Glide effortlessly into beautiful predictable dentistry by using your facebow. Keep your Earth in the window!

This is part 2 in a series where Dr. Mike Crete describes an conservative esthetic case where he combined Invisalign and veneers.  Part one looks at helping the patient become aware of the possibilities. Read on for the conclusion.

A Smile Dialogue

… All of this conversation took place in about 5 minutes at the end of the patient’s initial hygiene examination. I then invited him to return for a ‘complimentary smile analysis’ appointment where I would take a series of digital photos and then sit down with him and talk about what we could do to improve his smile.   

I find I can build trust and credibility with a new patient by offering to see them for this complimentary appointment. It only takes about 20 minutes and I typically ‘convert’ the patient to a records appointment (comprehensive exam, X-rays, and mounted study models).

The records appointment was scheduled. More co-discovery revealed how significant Drew’s self-esteem was impacted by his smile and his ‘baby face and baby teeth.’ The records appointment was followed by a diagnostic wax up (or a “3D Design” as I like to call it when talking to patients).

Then a consultation was done to review treatment options. This was a formal case presentation using Powerpoint, photos, and mounted models. Drew’s mother sat in on the consultation appointment.

By having accurately mounted study models on a semi-adjustable articulator, I was able to determine I could give Drew an ideal occlusion AND a pleasing smile. This would involve some minor tooth movement using Invisalign for 6 months and then restoring his upper and lower anterior teeth with conservative porcelain veneers. His posterior teeth were equilibrated during the restorative process. Also, an upper bite guard was fabricated for nighttime wear and added protection of the restorations.  

Drew graduated from college approximately 18 months after I first met him. He completed an internship during his final semester and then was hired by the Fortune 500 company immediately following graduation. He recently got married and said to me, “After I had my teeth done everything in my life started to fall into place. I graduated, got a great job, and met the love of my life. Thanks, doc.”  

Changing a smile and changing a life. It’s being able to impact the lives of others in this way that makes it so rewarding to practice dentistry!  

Dr. Crete discusses an anterior esthetic case from the initial conversation to finished treatment plan for a patient who lacked smile confidence.

Patient Profile

Drew became a new patient at my practice as a 20-year-old junior in college. His reasoning was: “Just to get my teeth cleaned.” During his initial hygiene appointment, he mentioned the “spot” on his front tooth (#9 – small pit filled with composite 10 years prior).  

He asked: “Can you put some new bond on there and make it match better? Even when my dentist did it the first time, it was always obvious.”

I heard his question as a window to ask further questions and find out a little bit more about him. At Pankey, we call this, ‘knowing your patient.’ It can start with an introduction to a new patient during a hygiene examination.  

Asking the Right Questions for Case Acceptance

I began by asking, “Do you know why you had the bonding done?” and “Did you have a cavity?”  

His answer was, “No, I have been playing hockey since I was really little. I was not always good about wearing my mouth guard and I chipped my teeth a lot.”   

Further questioning revealed he was referring to the enhanced mamelons and pitted enamel areas of his anterior teeth as “chips.”

His parents had elected not to have the chips repaired because they were told it was cosmetic treatment and their insurance would likely not pay anything.  

The Value of Open Dialogue

I then asked a few more open-ended questions like, “Is there anything about your smile you would change?”  

His answer: “Well, I always feel like I have little teeth and it makes me look like a little kid. I wanted braces when I was in junior high but my dentist told me I had a good bite and braces wouldn’t fix all the spaces I have.”  

Further dialogue with Drew revealed a significant concern he had about graduating from business school in a year and having to go through interviews looking like a little kid. He said, ”I worry no one will want to hire me because I look so young.”

To be continued…

White and brown spot lesions on the anterior teeth can be very distressing for the patient and a frustration for clinicians. Normally, they are decalcification or deposits on the teeth from fluoride or other minerals.

They do not require restoration. We are hesitant to do this and sacrifice good tooth structure, but esthetically they can really bother patients. They reduce a patient’s confidence in their smile. Recently, I have found a solution to this clinical situation that meets both the patient’s esthetic demands and my desire to be conservative.

Reversing Lesion Color on Anterior Teeth

Icon, from DMG America, is a translucent resin infiltrate that reverses the color of the lesion. It brings the tooth back to its natural color, requires no tooth preparation, and protects the tooth from further decalcification or progression into a carious lesion.

After we isolate with a rubber dam, the tooth is etched with a special etchant included in the kit. The protocol requires a longer etching time then we are accustomed to with other procedures.

After each etching procedure, we rinse and dry the tooth. Then we apply a special drying agent that allows us to evaluate the final result prior to proceeding with the resin.

If the tooth color has not yet been optimized, the etchant is applied again. This can be repeated up to five times. Once we have completed the etching process and confirmed the result with the drying agent, the resin is applied and then cured.

The entire procedure is done without any anesthesia and is very comfortable for the patient. Icon can be used on the facial and also on interproximal areas.

The resin is not visible on an x-ray, so the kit comes with a card to give the patient. This is so that if they see another dental office in the future, they are aware that the interproximal areas will still appear decalcified on an x-ray but have been fully infiltrated with resin.

I really enjoy offering this incredible, conservative esthetic service to my patients.

There are three critical components to the incisal edge anatomy of anterior teeth. Understanding the function and esthetics of the pitch and two bevels is essential to creating an ideal patient result.

How can a clinician re-create the full anatomic form of the tooth in ceramics and composite? 

In my last blog on this topic, I discussed the dimensions, characterization, esthetics, restorative approach and challenge of mimicking ‘pitch‘ esthetics. Now, I’ll delve into mastering the bevels to create superior restorative results. Combining an esthetic pitch with functional bevels will ensure a smooth composite or ceramic outcome.

Components of Incisal Edge Anatomy Function and Esthetics: Bevels

The two bevels can be found on alternately the labial and the lingual of the transition zone between the pitch and these surfaces. They are often called the leading edge and the trailing edge.

Bevels

Dimensions: The bevels on both sides have a variable width. They can be between less than a millimeter to multiple millimeters long.

Characterization: The bevels lengthen in patients who grind their teeth in an excursive pathway pattern. Patients who parafunction edge to edge might eliminate the bevel. This makes it easier to shear enamel off on the labial or lingual side of the tooth. It also could result in chipping the edge enamel.

Function: The bevel is a transition zone to create smooth functional movement passing from excursive movements onto the pitch. Intercuspal stops on lower incisors are often on or gingival to the bevel.

Whether you are finalizing an equilibration, the occlusion on composites, or ceramics, perfecting anterior guidance is all about both pitch and bevel surfaces. These critical components are a great example of marrying form and function in your technique.

What is your restorative approach for recreating incisal edge anatomy? We’d love to hear from you in the comments! 

The incisal edge anatomy of anterior teeth is quite complex. This complexity is fundamental to the esthetics of the tooth, as well as the function of incisors. How do we re-create the full anatomic form of the tooth in ceramics and composite? 

Components of Incisal Edge Anatomy Function and Esthetics: Pitch

When the full anatomic form is not precisely recreated, this can lead to esthetic and functional challenges. To successfully mimic this form, the clinician can rely on three components of incisal edges (from a lateral perspective): 1 pitch and 2 bevels.

We can visualize the pitch as the flat top of the incisal edge.

Pitch

Dimensions: Labio-lingual width of at least 1mm that increases from attrition or parafunction in edge to edge position.

Characterization: Pitch is not always parallel to the horizon and its relative position is dependent on the inclination of the incisor. Incisors are inclined just a little bit further to the labial at the incisal edge and the pitch has an upward slant toward the lingual.

Esthetics: The tooth shape and inclination results in an incisal edge esthetic of thinner enamel at the labio-incisal junction. It also creates the highly desirable visual translucence. Leveling the pitch to the horizon can change light reflection which is critical to esthetics of the tooth.

Restorative Approach: Often in ceramics we create a pitch that is level to the horizon and has decreased width of the pitch. This can compromise the esthetics of the translucency, but that can be gained back using stains.

Challenge: The challenge with this shape change in ceramics is that patients often sit in edge to edge position during parafunction. Insufficient pitch width may result in the patient experiencing functional challenges, not finding a comfortable spot to rest and increased parafunctional movement.

I’ll expand on understanding the two bevels in my next incisal edge anatomy blog …

What aspects of incisal edge anatomy do you find most challenging? Let us know in the comments!