Language: English Portuguese. The search for esthetic treatment has persisted in the routine of dental professionals. Following this trend, dental patients have sought treatment with the primary aim of improving smile esthetics.
The aim of this article is to present a protocol to assess patient's smile: The 10 Commandments of smile esthetics. The search for improved dentofacial esthetics persists in modern society. Thus, inspired by pretty faces and beautiful smiles, patients have sought treatment modalities to improve dentofacial esthetics and yield positive changes in their smile.
With a view to achieving ideal esthetic outcomes, some reference parameters must be followed. During many years, these guidelines were based on experts' opinions, 45789 in which case special attention should be given to studies conducted by Camara, 45 as they provide essential information on smile esthetics. On the other hand, these clinical guidelines are questionable, since esthetics is a subjective notion and tends to vary among different individuals and cultures.
Based on the pioneer research conducted by Kokich et al 11some authors sought digital imaging technology to search for more scientific and consistent references. Since then, several smile variables have been researched as follows: Smile arc; 12 buccal corridor; 13 amount of gingival exposure at smiling; 131415 presence of gingival and incisal asymmetry; 1111617 presence of anterosuperior diastema; 314 presence of midline shift and changes in axial proclination; 1117 maxillary incisors ratio, size and symmetry; 112 among others.
While the wide variety of articles studying those characteristics is of paramount importance to dental literature, it hinders the work of clinicians seeking simple and practical treatment protocols. Professionals usually have a few questions: Where should smile esthetic planning begin?
What are the most relevant aspects considered in esthetic treatment? Which scientific references should be considered in a given therapeutic approach?
The aim of this article is to present a protocol to assess patient's smile esthetics: "The 10 commandments of smile esthetics". It particularly aims at simplifying clinical applicability and interdisciplinary planning of smile treatment. With a view to allowing reading to flow as well as for didactic reasons, the issue discussed herein is divided into three main topics: 1 Why should smile be assessed?
Two major aspects must be highlighted. First, interdisciplinary treatment, i. Second, although most 10 commandments are scientific-based, treatment protocol should not be universally applied, but function as a starting point, since the concept of beauty significantly varies. Thus, all commandments presented herein must be subject to discussion among clinicians and patients so as to ensure individualized and satisfactory esthetic planning.The purpose of this study was to quantify some clinical parameters useful as esthetic guidelines when gingival contour is modified and to compare the left and right sides of six maxillary anterior teeth.
Maxillary casts mounted on an articulator according to the axis orbital plane were photographed from 35 young adults. The angle formed between the gingival line and maxillary midline GLA and the distance between the gingival zenith of the lateral incisor and the gingival line were measured LID using a flexible protractor and digital vernier caliper, respectively. The GLA measurements of the left side The mean LID measurement was 0. A directional asymmetry was shown with the right side higher than the left side.
Along with the other parameters related to dental esthetics, these clinical parameters may serve as esthetic guidelines and may enable us to obtain a more predictable outcome.
The search of beauty can be traced to the earliest civilizations. Dental art has been part of this quest to enhance the esthetics of the teeth and mouth. Mathews in expressed dentist's responsibility to preserve, create, or enhance a pleasing smile without impairing function.
The anatomy of smile is an integral part of dentistry, involving close scrutiny of all elements of the oral region. The crafting of ideal smile requires analysis and evaluations of the face, lips, gingival tissues, and teeth and an appreciation of how they appear collectively.
Such an ideal smile depends on the symmetry and balance of the facial and dental features. Recognizing that form follows function and the anterior teeth that serve a vital role in the oral health of the patient is paramount.
Using a comprehensive approach in diagnosing and treatment planning of the esthetic cases can help achieve the smile that best enhances the overall facial appearance of the patient, and provides additional benefit of enhanced oral health.
The lips form the frame of smile and define the esthetic zone. Its position during smiling determines the amount of gingival display. To predict the final esthetic result and achieve optimal results in gingival contour rehabilitation crown lengthening, implant, restorative, and orthodontic therapyit is important to take gingival contours into account during treatment planning. One significant feature of gingival morphology is the gingival line, which is defined as the line joining the tangents of the gingival zeniths of the central incisor and canine.
The gingival zenith is the most apical aspect of free gingival margin. A total of 35 young adults were randomly selected at the Rural Dental College, Loni, within the age group of 21 to 30 years without any dental deformity or patient undergone any periodontal, surgical, or orthodontic treatment involving especially the maxillary anterior teeth.
Alginate impressions of maxillary arch were made in stock trays and poured in dental stone according to manufacturer's instructions. Face bow record of every patient was made and the maxillary casts were mounted onto the semi-adjustable articulator Whipmix series. The face bow transfer was done to avoid any discrepancy relating the axis orbital plane, affecting the relation of zenith points of both maxillary central incisor and canines.
Any discrepancy in the casts as well as the orientation of maxillary plane found was repeated again for individual sample. To avoid any bias, the impressions and the face bow transfers were taken by the same operator. Landmark identification and measurement: The gingival zenith was made with indelible marking pencil for all the maxillary anterior teeth, the maxillary midline was marked then, and finally the gingival line marked and joined to the midline [ Figure 1 ].
Marking of midline; line connecting midline and zenith of maxillary central incisor and canine gingival line. This gingival line marked created an angle with the respective gingival zeniths of both left and right sides. Since the maxillary casts were a 3-dimensional structure, the measurement of the same was done by recording a print out made by the protractor on a transparent sheet to get the exact angle of each zenith on both the sides, respectively.
The highly sensitive photographic method was avoided as it converts the cast into a 2-dimensional structure and flattens the relation of each gingival line respectively. Measurement of distance between the zenith of lateral incisor and gingival line using digital vernier caliper.
The lateral incisor's relationship to the gingival line was evaluated by using Digital vernier caliper and the readings were noted as LID measurements. Positive values of the lateral incisor were coronal to the gingival line, whereas negative values were apical to gingival line.Adam J.
Martin, Peter H. Buschang, Jimmy C. Boley, Reginald W. Taylor, Thomas W. The aim of this study was to assess the impact of various sized buccal corridors BCs on smile attractiveness. One female smiling photograph, displaying first molar to first molar M1—M1was digitally altered to produce 1 smiles that filled 84, 88, 92, 96, and per cent of the oral aperture; 2 second premolar to second premolar smiles PM2—PM2 that filled 84, 88, 92, and 96 per cent of the oral aperture; and 3 smiles with asymmetrical BC that filled 88, 90, 94, and 96 per cent of the oral aperture.
The 18 smiles produced were evaluated by 82 orthodontists 70 males and 12 females and 94 laypeople 40 males and 54 females.
Paired t -tests were used to evaluate differences within the orthodontist and laypeople groups: independent t -tests were used to compare the two groups.
Gingival zenith and its role in redefining esthetics: A clinical study
The effect of age and gender on the ratings was evaluated by two-way analysis of variance. Orthodontists rated only two of eight asymmetrical smiles as less attractive than would be expected for symmetrical smiles with similar arch widths; laypeople did not rate any asymmetrical smiles as less attractive than would be expected. Rater age and gender did not significantly influence the impact of BCs on smile attractiveness.
Physical attractiveness plays an important role in how we view ourselves and how we are viewed by others Dion et al. Dentofacial attractiveness is a major determinant of overall physical attractiveness Linn, ; Shaw et al. Individuals mainly focus on other people's eyes and mouths during interpersonal interaction, with little time spent on other facial features Miller, In the mind of the general public, the smile ranks second only to the eyes as the most important feature in facial attractiveness Goldstein, Smile attractiveness includes a number of important components.
First, the smile arc should follow the path defined by the edges of the maxillary central incisors, lateral incisors, and tips of the canines Frush, ; it should be consonant with the curvature of the lower lip Hulsey, ; Sarver, The gingival margins of the central incisors should be positioned apical to those of the lateral incisors and at the same level as the canines Kokich, There should be approximately 1. Whiter teeth are aesthetically pleasing to patients, regardless of whether or not dentists agree Alkhatib et al.
The golden proportion, while a useful guide for tooth size relationships Levin, ; Ricketts,does not seem to hold for the majority of natural dentitions Preston, Females tend to prefer smiles with round and square-round teeth, while males prefer smiles with square teeth Anderson et al.
One of the more controversial aspects of smile attractiveness pertains to buccal corridor BC size, defined variably as the space between the buccal surfaces of the maxillary teeth and the corners of the mouth during a smile.
Assuming that small BCs make a smile more attractive Dierkes, ; Blitz, ; Morley and Eubank, ; Sarver, ; Sarver and Ackerman,orthodontic expansion has been proposed to improve smile attractiveness Sarver, ; Sarver and Ackerman, Importantly, Moore et al. Studies indicating that BCs do not impact on smile attractiveness have used inter-canine width to define BC size Hulsey, ; Roden-Johnson et al.
In order to provide clinical guidelines, it is important to determine whether orthodontists and laypeople perceive BCs differently.Botox has been primarily used in cosmetic treatment for lines and wrinkles on the face, but the botulinum toxin that Botox is derived from has a long history of medically therapeutic uses. For nearly 13 years, until the introduction of Botox Cosmetic inthe only FDA-approved uses of Botox were for crossed eyes strabismus and abnormal muscle spasms of the eyelids blepharospasm.
Since then botulinum A, and the seven other forms of the botulinum toxin, have been continuously researched and tested. Botox is a neurotoxin derived from bacterium clostridium botulinm. The toxin inhibits the release of acetylcholine ACHa neurotransmitter responsible for the activation of muscle contraction and glandular secretion, and its administration results in reduction of tone in the injected muscle. The use of Botox is a minimally invasive procedure and is showing quite promising results in management of muscle-generated dental diseases like Temporomandibular disorders, bruxism, clenching, masseter hypertrophy and used to treat functional or esthetic dental conditions like deep nasolabial folds, radial lip lines, high lip line and black triangles between teeth.
Many of us think of Botox primarily as a cosmetic treatment for lines and wrinkles on the face, but the botulinum toxin that Botox is derived from has a long history of medically therapeutic uses such as in cervical dystonia, hyperhidrosis, strabismus and blepharospasm. Botox has now been increasingly used in dentistry as well due to its therapeutic uses in treatment of certain oral conditions. Although botulinum toxin is a lethal, naturally occurring substance, it can be used as an effective and powerful medication [ 3 ].
Three forms of botulinum toxin type A Botox, Dysport and Xeomin and one form of botulinum toxin type B MyoBloc are available commercially for various cosmetic and medical procedures. And 0. Injecting overactive muscles with minute quantities of botulinum toxin type-A results in decreased muscle activity. Botulinum toxin type-A inhibits the exocytosis of acetylcholine on cholinergic nerve endings of motor nerves [ 4 ], as it prevents the vesicle where the acetylcholine is stored from binding to the membrane where the neurotransmitter can be released.
Botulinum toxin achieves this effect by its endopeptidase activity against SNARE proteins, which are kd synaptosomal associated proteins that are required for the docking of the ACH vesicle to the presynaptic membrane [ 5 ]. Botulinum toxin type-A thus blocks the release of acetylcholine by the neuron. This effectively weakens the muscle for a period of three to four months [ 6 ]. Temporomandibular disorder TMD is a term used to describe a number of diseases affecting masticatory function, which may include true pathology of the temporomandibular joint as well as masticatory muscle dysfunction [ 78 ].
The majority of TMD cases include a myogenic component [ 910 ] and muscular spasticity secondary to bruxism, external stressors, oromandibular dystonia, and psychomotor behaviours are common aetiologic factors of TMD [ 11 ]. These techniques are invasive, irreversible, and expensive for the majority of patients. Techniques currently employed for aesthetic, conservative restorations may not withstand the parafunctional forces continually applied by some patients.
Thus, many of these treatment options are not ideal for all patients, and muscular relaxation with botulinum toxin A is a viable alternative. When a muscle relaxant is used with the muscles of mastication, this clenching reflex can be reduced or eliminated [ 12 ]. Because a very small percentage of available force is required to masticate food, a slight relaxation of muscle function reduces bruxing and is usually insufficient to affect chewing and swallowing [ 13 ].
Botox and Dermal fillers can provide immediate volume to areas around the mouth, such as the nasolabial folds, marionette lines, and lips to create the proper lip lines, smile lines, and phonetics. Botox can also be used in a lip deformity where the lip rises more on one side than the other. Food particles accumulate in the space and create aesthetic issues. Treatment outcome usually last for eight months or longer—at which point the treatment needs to be repeated. Black triangles between the teeth can be filled up by Botulinum toxin A [ 14 ].
Botulinum neurotoxin has also shown promise in alleviating the symptomatology of bruxism. One of the earliest reports on use of botulinum toxin type A for bruxism was by Van Zandijcke and Marchau [ 15 ], who described the successful treatment of a brain-injured patient with severe bruxism with U of a botulinum toxin type A injections to the temporalis and masseter muscles.After you enable Flash, refresh this page and the presentation should play.
Get the plugin now. Toggle navigation. Help Preferences Sign up Log in. To view this presentation, you'll need to allow Flash. Click to allow Flash After you enable Flash, refresh this page and the presentation should play. View by Category Toggle navigation. Products Sold on our sister site CrystalGraphics. Title: Local Anesthetic. Description: Nerve Block. In this type of anesthesia, a local anesthetic is injected around a nerve that leads to the operative site. Tags: anesthesia anesthetic local.
Latest Highest Rated. Title: Local Anesthetic 1 Local Anesthetic A local anesthetic is an agent that interrupts pain impulses in a specific region of the body without a loss of patient consciousness. Normally, the process is completely reversible. It was first introduced to clinical ophthalmology as a topical ocular anesthetic.
InDr. William Stewart Halsted was the first to describe the injection of cocaine into a sensory nerve trunk to create surgical anesthesia. They are hydrolyzed in plasma by pseudo-cholinesterase. One of the by-products of metabolism is paraaminobenzoic acid, the common cause of allergic reactions seen with these agents 6 Amides These include lidocaine, mepivicaine, prilocaine, bupivacaine, and etidocaine. They are metabolized in the liver to inactive agents.
True allergic reactions are rare especially with lidocaine 7 Mechanism of Action Local anesthetics work to block nerve conduction by reducing the influx of sodium ions into the nerve cytoplasm. They block the sodium channellocal anesthetics bind directly to the intracellular voltage-dependent sodium channels Block primarily open and inactive sodium channels, at specific sites within the channel 8 Local anesthetics abolish sensation and in higher concentrations, motor activity in a limited area of the body without producing unconsciousness.
The small, un-myelinated nerve fibers, that conduct impulses for pain, temperature, and autonomic activity, are most sensitive to actions of local anesthetics. Chemical compounds which are highly lipophilic tend to penetrate the nerve membrane more easily, such that less molecules are required for conduction blockade resulting in enhanced potency.
Therefore, to avoid a systemic toxic reaction to a local anesthetic, the smallest amount of the most dilute solution that effectively blocks pain should be administered. Some patients are hypersensitive very rare cases There are two basic types of local anesthetics the amide type and the ester type. A patient who is allergic to one type may or may not be allergic to the other type. Local anesthetics, if absorbed systematically in excessive amounts, can cause central nervous system CNS excitement or, if absorbed in even higher amounts, can cause CNS depression.
Local anesthetics if absorbed systematically in excessive amounts can cause depression of the cardiovascular system. Peripheral vascular action arteriolar dilation except cocaine which is vasoconstrictive Hypotension.
Hematological SE Methemoglobinemia 19 Administraion of Local Anesthetcs Infiltration Anesthesia Local infiltration occurs when the nerve endings in the skin and subcutaneous tissues are blocked by direct contact with a local anesthetic, which is injected into the tissue.
Infiltration Anesthesia is used primarily for surgical procedures involving a small area of tissue for example, suturing a cut.
This technique is often used during examination procedures involving the respiratory tract, the eye etc For topical application, the local anesthetic is always used without epinephrine. Usually more concentrated forms of local anesthetic solutions are used for this type of anesthesia. Peridural Anesthesia. This type of anesthesia is accomplished by injecting a local anesthetic into the peridural space.
In spinal anesthesia, the local anesthetic is injected into the subarachnoid space of the spinal cord 23 Vasoconstrictors Vasoconstrictors decrease the rate of vascular absorption which allows more anesthetic to reach the nerve membrane and improves the depth of anesthesia.Thirty days later, further assessment was performed to determine the reproducibility. The duration of each exam was measured in seconds with a stopwatch. The indices were compared by a panel of three experts in orthodontics to evaluate validity.
The intra-examiner reliability evaluation resulted in an intraclass correlation coefficient of 0. Both indices presented good reproducibility and validity. Since the s, considerable effort has been made to develop a valid, reproducible and standardised orthodontic index. Occlusal indices can be defined as methods for determining the level of treatment need or the amount of deviation from normal occlusion and can be used for the evaluation of individual patients and populations [ 3 ].
Occlusal indices such as the DAI [ 2 ] and the IOTN [ 1 ] are used to determine the need or priority for orthodontic treatment in epidemiological surveys. The Dental Aesthetic Index DAIadopted by the World Health Organization, evaluates 10 occlusal characteristics: overjet, negative overjet, tooth loss, diastema, anterior open bite, anterior crowding, anterior diastema, width of the anterior irregularities mandible and maxilla and antero-posterior spring relationship [ 2 ].
The DAI has four stages of malocclusion severity: a score lower than or equal to 25 no or slight treatment needa score between 26 and 30 elective treatmenta score between 31 and 35 treatment highly desirable and a score greater than 36 treatment mandatory [ 4 ]. The DHC-IOTN consists of a hierarchical scale with five levels: level 1 represents little or no need for treatment and level 5 represents a great need for treatment. It evaluates the malocclusion by means of five characteristics: tooth loss, overjet, crossbite, displacement of the contact point, and overbite [ 1 ].
Moreover, the IOTN has been described as an index for easy use [ 1 ]. This study was carried out between July and October The study involved the assessment of a sample of pairs of dental casts selected randomly from the archive of the Specialization Course in Orthodontics at the Faculty of Dentistry, Universidade Federal de Minas Gerais, Brazil.
Esthetics for Pediatric Patients: Lecture
This archive contains models of oral cavities of all orthodontic patients from Universidade Federal de Minas Gerais. Models in inadequate conditions with fractures in casts and models of patients who had received previous orthodontic treatment were not included. The age of participants whose models were included in this study ranged from 12 to 15 years, an age group recommended in studies of occlusal indices by several authors [ 24 ].
The patients, whose models were evaluated, were at early permanent dentition. The sample size calculation was performed by considering the The reproducibility analysis was carried out before the validation analysis.
After the reproducibility assessment, the study models were examined by the researcher, an expert in orthodontics, to assess the ability of both indices to identify orthodontic treatment need. The aesthetic component of the IOTN was not assessed, as it presents poor association with the clinical condition when used in models [ 11 ]. The gold standard of orthodontic treatment need was determined by three professors who are experts in the area of orthodontics with at least 10 years of clinical experience [ 12 ].
They examined the study models separately. Where there was disagreement in the assessment of the models, there was a discussion among the researchers to reach a consensus [ 12 — 14 ]. The time needed to evaluate the indices was measured by a digital stopwatch by the same researcher who evaluated the models.
The comparison between time needed to evaluate the indices was done by the Wilcoxon test. The validation of the indices was done by calculating sensitivity, specificity, positive predictive value, negative predictive value and accuracy area under the receiving-operating characteristic curve [ROC curve].
An optimum cutoff point for each of the indexes was determined by plotting ROC curves. The minimum and maximum values were 19 and The intra-rater reliability assessment resulted in an intraclass correlation coefficient of 0.
The accuracy of the indices, as reflected by the ROC curve, was also presented Figure 1.An organized and systematic approach is required to evaluate, diagnose and resolve esthetic problems predictably.
It is of prime importance that the final result is not dependent only on the looks alone. Our ultimate goal as clinicians is to achieve pleasing composition in the smile by creating an arrangement of various esthetic elements. This article reviews the various principles that govern the art of smile designing.
The literature search was done using PubMed search and Medline. This article will provide a basic knowledge to the reader to bring out a functional stable smile. Of course, the importance given to a beautiful smile is not new. The search for beauty can be traced to the earliest civilizations; both the Phoenicians app BC and Etruscians app BC carefully carved animal tusks to simulate the shape, form and hue of natural teeth.
It was not until the 18th century that dentistry was recognized as a separate discipline and its various branches were established. Pierre Fauchard — of France, the leader of the movement, together with several colleagues modernized and promoted dentistry and also advocated esthetic practices.
The literature search was done using pub med search and medline. The goal of an esthetic makeover is to develop a peaceful and stable masticatory system, where the teeth, tissues, muscles, skeletal structures and joints all function in harmony Peter Dawson.
It is very important that when planning treatment for esthetics cases, smile design cannot be isolated from a comprehensive approach to patient care. Achieving a successful, healthy and functional result requires an understanding of the interrelationship among all the supporting oral structures, including the muscles, bones, joints, gingival tissues and occlusion.
Harmonizing an esthetics smile requires a perfect integration of facial composition and dental composition. The facial composition includes the hard and soft tissues of the face. The dental composition relates more specifically to teeth and their relationship to gingival tissues.
A smile design should always include the evaluation and analysis of both facial and dental composition. Facial beauty is based on standard esthetic principles that involve proper alignment, symmetry and proportion of face. Analyzing, evaluating and treatment planning for facial esthetics often involve a multidisciplinary approach which could include orthodontics, orthognathic surgery, periodontal therapy, cosmetic dentistry and plastic surgery.
Thus, esthetic approach to patient care produces the best dental and facial beauty. But in our clinical practice, unless and otherwise there is an obvious discrepancy in the face, we restrict our smile makeover to the dental composition only. There are two facial features which do play a major role in the smile design:. The interpupillary line should be perpendicular to the midline of the face and parallel to the occlusal plane.
Lips are important since they create the boundaries of smile design. If we come across major discrepancies in the above-mentioned two factors, then we have to seriously consider the correction of the facial composition, before we venture into the correction of the dental composition.
In classical terms, the horizontal and vertical dimensions for an ideal face are as follows:. The distance between the eyebrow and chin should be equal to the width of the face [ Figure 1 ]. The facial height is divided into three equal parts from the fore head to the eyebrow line, from the eyebrow line to the base of the nose and from the base of the nose to the base of the chin.
The lower part of the face from the base of the nose to the chin is divided into two parts, the upper lip forms one-third of it and the lower lip and the chin two-thirds of it [ Figure 2 ]. The basic shape of the face when viewed from the frontal aspect can be one of the following:. These factors play a role in determining the tooth size, shape and the lateral profile; in short, the tooth morphology is dependent on the facial morphology.
The role of each of the above-mentioned factors in smile designing is given below. The midline refers to the vertical contact interface between two maxillary centrals. It should be perpendicular to the incisal plane and parallel to the midline of the face.
Minor discrepancies between facial and dental midlines are acceptable and, in many instances, not noticeable. The maximum allowed discrepancy can be 2 mm and sometimes greater than 2 mm discrepancy is esthetically acceptable so long as the dental midline is perpendicular to the interpupillary line.
Various anatomical landmarks such as midline of the nose, forehead, chin, philtrum, interpupillary plane can be used as guides to the midline assessment.