esthetics

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Author:
emm64
ID:
276569
Filename:
esthetics
Updated:
2014-06-11 10:03:38
Tags:
esthetics
Folders:
spr14
Description:
esthetics
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  1. Full Face
    • -3 feet from the background
    • - The patient’s head should be vertical left-to-right and front-to-back
    • - Autofocus is useful for this image only
    • - Set the aperture to f/8 (if the image is too dark set to f/5.6)
  2. Basic Diagnostic Image Series
    • 1. Full face smiling
    • 2. Lips in Repose
    • (“M” position)
    • 3. Maximum gingival display
    • (“E” position)
    • 4. Retracted
    • 5. Maxillary occlusal
    • 6. Mandibular occlusal
  3. Posterior Restoration Image Series
    • 1. Shade Image (RAW)
    • 2. Pre-operative Occlusal
    • 3. Post-operative Occlusal
  4. Anterior Restoration Image Series
    • 1. Full face smiling
    • 2. Pre-op
    • 3. Prep
    • 4. Retracted
    • 5. Shade
    • 6. Post-OP
  5. Delicate Characteristics
    • Rounded arch form
    • Rounded corners
    • Anteriors closely follow the lower lip
    • Laterals overlap centrals
    • Smaller laterals and cuspids
    • Sharp canines
  6. Rugged:
    • Angular outlines
    • Larger laterals and canines
    • Square arch form
    • Centrals overlap laterals
    • Blunt canines
  7. The Five Esthetic Keys*
    • Midline
    • Incisal Edge Position
    • Incisal Plane/Smile Line
    • Occlusal Plane
    • Gingival Level
  8. Philtrum
    midline face
  9. Papilla
    midline teeth
  10. Contact
    • most variable and visible of midline elements
    • embrasure form
    • progress cervical (and size increase)(from incisal -> distal)
  11. most variable and visible of midline elements
    contact
  12. Dental Midline
    • People don’t notice facial/dental midline iscrepancies
    • People DO notice inclination of dental midline
    • Midlines don’t need to be in center of face, but they must be straight!
  13. midline captured with:
    facebow
  14. midline asymmety etiology
    • missing teeth
    • skeletal
  15. Axial tooth inclinations are ____ to the midline
    NOT parallel
  16. incisal plane and occlusal plane:
    are on same level
  17. Incisal plane coronal to occlusal plane?
    Anteriors are probably too long.
  18. Incisal plane apical to occlusal plane?
    Anteriors are probably too short.
  19. labial surface is _____ to occlusal plane
    perpendicular
  20. inclination is ____ degrees from occl. plane, inclination should probably altered.
    > 5 to 10
  21. Are teeth too long?
    • 1. Evaluate phonetics
    • Fricative sounds (F,V) wet-dry line
    • 2. Evaluate tooth display with lip at rest
    • “M” position
    • 3. Evaluate lip mobility
    • “E” position
    • Average lip moves 6-8 mm from rest to full smile
  22. Average tooth display of ____ at rest is pleasing in most people
    1-3 mm
  23. Average incisor display at rest for caucasian females
    • Age 30: 3.37 mm max. 0.5 mm mand.
    • Age 50: 0.95 mm max. 2.0 mm mand.
    • Age 70: 0 mm max. 2.95 mm mand
  24. Average lip moves ____ from rest to full smile
    6-8 mm
  25. A 1-3 mm tooth display at rest and 6-8 mm of lip movement give range of 7-11 mm of tooth and tissue exposure on the average
    True
  26. During full smile, show free gingival margin of centrals that are
    9.5 – 11 mm long
  27. Incisal Plane =
    line formed by the canine tips and incisal edges of maxillary anteriors
  28. Harmony between incisal plane and
    curvature of lower lip
  29. Occlusal Plane =
    line formed between cusp tips of canine, premolars, and molars
  30. Ideal Goal: Extension of incisal plane is in harmony with
    lower lip
  31. maxillary anterior form
  32. mand anterior form
  33. Illusions to increase visibility
    • Increased contrast, light reflection
    • Shadows create depth
    • Light creates prominences
    • Vertical lines accent length
    • Horizontal lines accent width
  34. Increased light deflection____
    diminishes visibility
  35. Shadows create
    depth
  36. Light creates
    prominences
  37. Vertical lines accent
    length
  38. Horizontal lines accent
    width
  39. to make a tooth appear wider MD
    • adjust lateral prominences proximally
    • diminish curvature of central prominence mesiodistally
    • diminish the length of the central prominence
  40. to make the tooth appear narrorwer
    • adjust lateral promeniences (line angles to center)
    • increase curvature of central prominence
    • increase length of central prominence
    • increase IP staining
  41. shortening techniques
    • adjust incisal incline lingually
    • diminish length of central prominence
    • accentuate horizontal characterizations
    • flatten middle 1/3rd of labial surface to broaden light surface reflection
    • color: darken gingival 1/3rd, diminish interproximal staining
  42. lengthening techniques
    • flatten labial gingivoincisally
    • increase central prominence length
    • round labial surface mesiodistally
    • accentuate vertical characterizations
    • color: lighten gingival 1/3rd
    • increase IP staining
  43. Gingival Levels Are Driven By
    • Tooth size
    • width:length ratios
    • Desired gingival display
  44. The “Golden Proportion”:
    • Pythagoras
    • ratio of (smaller/larger) = ratio of (larger/whole)
  45. Anterior teeth in golden proportion to each other
    • lateral is approx. 60% as wide as central
    • canine is approx. 60% as wide as lateral
  46. Golden Proportion applied to smile design:
    • Based on apparent M-D width of anteriors
    • Assessed only with photos!
    • Not an absolute criterion of optimal esthetics
    • starting point for designing relative widths
    • A diagnostic tool
    • lateral is approx. 60% as wide as central
    • canine is approx. 60% as wide as lateral
  47. The Golden Percentage*
    • Not dependent on width of laterals alone
    • Evaluates each tooth for its contribution to symmetry, dominance, and proportion
    • Teeth with identical widths generate identical percentages
    • Asymmetry is clearly identifiable and quantifiable
  48. Golden %
  49. mandibular golden %
    22-15-12
  50. normal/ideal” width:length ratio for the central incisor is
    75% to 80%
  51. To calculate correct length for a given width, use the following formula:
    • width x 1.25 = 80% width:length ratio
    • width x 1.38 = 73% width:length ratio
    • width x 1.50 = 67% width:length ratio
    • Example: How long should an 8 mm central incisor be?
    • 8 x 1.25 = 10 mm (80% width:length ratio)
    • 8 x 1.38 = 11 mm (73% width:length ratio)
    • 8 x 1.50 = 12 mm (67% width:length ratio)
    • The central can be 10 – 12 mm long and still look acceptable.
  52. Does width of laterals matter?
    • Threshold values for distance from ideal:
    • GPs and Orthodontists: 3 mm less than ideal
    • Lay people: 4 mm less than ideal
    • Bottom Line: Symmetry of laterals, not size, is KEY.
  53. Gingival margins are positioned to create the desired tooth size relative to
    the incisal edge.
  54. The incisal edge is NOT positioned to create the correct tooth size relative to
    FGM levels.
  55. Gingival levels
    • Determine tooth size/position first.
    • Avoid using gingiva as a reference to position incisal edges – gingiva can move with eruption or recession.
    • Tooth asymmetry is more noticeable than gingival asymmetry
  56. How much gingiva can show?
    • Threshold values for distance from ideal:
    • GPs and lay people will accept up to 3 mm
    • Orthodontists will accept up to 2 mm
    • Bottom Line: Gingival display of up to 3 mm will be acceptable for most patients
  57. Differential diagnosis for a gummy smile
    • Short upper lip
    • Hypermobile lip
    • Vertical maxillary excess (VME)
    • Anterior over-eruption
    • Wear + compensatory eruption
    • Altered active eruption
    • Altered passive eruption
  58. If excessive gingiva is present, evaluate crown length
    • Short crown length:
    • Wear/comp. eruption
    • Altered eruption
    • Normal crown length:
    • Short upper lip
    • Hypermobile lip
    • VME
    • Anterior over-eruption
  59. Excessive gingiva visible only in anterior?
    Anterior over-eruption
  60. Visible in anterior and posterior?
    short or hypermobile lip, or VME
  61. Planes coincide:
    short or hypermobile lip, or VME
  62. Incisal plane coronal to occl. plane, and excessive gingiva visible in anterior only:
    anterior over-eruption
  63. Planes coincide, and excessive gingiva visible in anterior and posterior :
    short or hypermobile lip, or VME
  64. Evaluate tooth display at rest.
    • Normal:
    • hypermobile lip
    • Excessive tooth display at rest:
    • VME, short u. lip, ant. over-eruption
  65. Glabella to base of nose should =
    base of nose to bottom of chin with face at rest and teeth in occlusion.
  66. Lower face > midface:
    probably VME
  67. Lower face = midface:
    short u. lip or anterior over-eruption
  68. Evaluate lip length.
    • Measure from base of nose to bottom of lip during smile w/teeth in occlusion.
    • Normal range:
    • Female 20-22 mm
    • Male 22-24 mm
  69. Normal eruption
    • Active: Anatomic crown erupts out of alveolus until CEJ is 1.5 – 2 mm from crest of bone.
    • Passive: Gingiva recedes until sulcus depth is 1 – 2 mm.
    • Diagnosis: Facial probing of 1 – 2 mm w/ CEJ easily probed.
  70. Altered Active Eruption
    • Crown does not erupt completely out of bone.
    • CEJ remains covered by or in close proximity to bone.
    • Diagnosis: unable to locate CEJ w/probe
  71. Altered Passive Eruption
    • Normal active eruption
    • Gingiva fails to recede normally, leaving sulcus of 3-4 mm or greater.
    • Diagnosis: Facial probing of 3-4 mm w/ CEJ easily probed.
  72. Short upper lip tx
    none
  73. Hypermobile lip tx
    none
  74. Vertical maxillary excess (VME) tx
    orthognathic
  75. Anterior over-eruption tx
    ortho, crown lengthening, restoration
  76. Wear + compensatory eruption tx
    Crown lengthening or intrusion + restoration
  77. Altered active eruption tx
    Crown lengthening w/ osseous
  78. Altered passive eruption tx
    Mucogingival surgery
  79. Ideal tooth/gingiva
    • Tissue on centrals is at same level and even with or apical to tissue on canines
    • Tissue on laterals is same height on each side and coronal to tissue on centrals by 0.5-1.5 mm
    • Tissue on canines is at same level on each side and equal to or slightly apical to tissue on centrals.
  80. Determinants of occlusion
    • TOOTH CONTACT
    • Lower incisor position
    • Overbite and overjet
    • Lingual of max. anteriors
    • Lower buccal cusps
    • Upper palatal cusps
    • Lower lingual cusps
    • Fossae
    • CONDYLAR POSITION
    • Determine condylar position
    • Centric Relation: The maxillomandibular relation in which the condyles articulate with the thinnest avascular portion of their respective discs with the complex in the anterior superior position against the shapes of the articular eminences. This position is independent of tooth contact. This position is clinically discernable when the mandible is directed superiorly and anteriorly. It is restricted to a purely rotary movement about the transverse horizontal axis.
  81. Facebow
    To register the relationship of the patient’s maxillary arch in three planes of space and transfer this information into an articulator that can be adjusted to simulate the patient’s jaw movements.
  82. If space is inadequate and patient desires the esthetics of the new maxillary incisor position,
    • Only 2 options exist:
    • Shorten or reposition the lower incisors
    • Open the vertical dimension
  83. 5 Steps to Ideal Function
    • Determine condylar position
    • Determine vertical dimension
    • Make all teeth touch during centric closure in this condylar position and this VDO
    • Eliminate any posterior tooth contacts in eccentric movements
    • Create a dental envelope of function in harmony with the patient’s neuro-muscular envelope of function
  84. Resin composite inlays/onlays Advantages over direct composite restorations:
    • Control of adaptation, contours, contact
    • Shrinkage occurs BEFORE placement
    • Better physical properties
    • Lab polymerization
    • Wear resistance slightly better than direct
    • Advantages over indirect ceramic restorations:
    • Less brittle – more fracture resistant
    • Easy to modify/repair
    • BUT…
    • Less wear resistance than ceramic
  85. Indirect Resin Composite Brand
    BelleGlass HP (Kerr)
  86. Sintering
    • Heating closely packed particles to a temperature just below the melting point
    • Achieves interparticle fusion with a concomitant increase in density
  87. Dental Porcelain properties
    • Biocompatible
    • High hardness
    • High compressive strength
    • Insoluble in oral environment
    • Excellent optical properties
    • Translucency → → → → Opacity
    • BRITTLE!
    • LOW tensile strength
    • Inability to flex
    • Opposing tooth wear
  88. Feldspathic
    • Feldspar + quartz + kaolin + metal oxides
    • Most commonly used dental porcelain
    • PFM crowns, porcelain veneers
    • Low flexural strength (100 – 200 MPa)
    • Low-Fusing Feldspathic
    • Addition of K+ and Boron
    • lower firing temp
    • higher solubility
    • Finer crystalline structure
    • Polishable
    • Less abrasive
    • Commonly used for corrections
    • (adding contact, etc.)
  89. Glass Ceramic
    • An amorphous glassy matrix phase + crystalline phase(s)
    • Produced by the controlled nucleation and growth of crystals in the glass
    • The crystalline phase(s) reinforce the glass matrix (increased flexural strength).
  90. Glass ceramic vs feldspathic
    Controlled growth of crystals in the glass:
  91. More homogeneous than sintered porcelains
    • More consistent physical properties
    • Less abrasive
    • Wear coefficient similar to enamel
    • Flexural strength > feldspathic porcelain
  92. IPS Empress
    • Leucite reinforced glass-ceramic
    • Fabrication: wax patterninjection molding (pressing)  layering/staining
    • Flexural strength – up to 200 MPa
  93. Emax
    • Lithium-disilicate reinforced glass-ceramic
    • Fabrication: wax patterninjection molding (pressing) OR CAD/CAM
    • Flexural strength  400 MPa
    • Layered fabrication
    • e.max substructure (for strength)
    • Veneer of sintered porcelain (for esthetics)
    • Monolithic” fabrication
    • Press and stain – no layering of sintered ceramic
  94. Ceramic Core Materials
    • Glass-infiltrated ceramics:
    • Alumina
    • Spinel
    • Alumina w/Zirconia
    • Polycrystalline ceramics:
    • Densely sintered high purity Al2O3
    • Zirconia (Y-TZP
  95. Polycrystalline ceramics
    • Densely sintered ceramic
    • Almost entirely crystalline phase - no amorphous glass matrix
    • “Pure” or of “high purity” due to virtual absence of glass matrix
    • Examples
    • alumina ceramic (e.g. original Procera All-Ceram)
    • various zirconia ceramic products (e.g. Lava)
  96. Zirconia
    • A crystal material capable changing crystal structure when under stress
    • At zone of stress concentration (crack), zirconia undergoes a phase transformation to a lager volume crystal structure
    • This “transformation toughening” resists crack propagation, the primary failure mode of ceramic restorations
    • LAVA
  97. Material choice is ______ driven
    • functionally (posterior)
    • esthetically (anterior)
  98. Material choice questions
    • Is the tooth endodontically treated?
    • Yes  gold onlay
    • gold crown
    • PFM crown
    • zirconia crown
    • lithium disilicate-reinf. g-c crown
    • No  next question…
    • Is the remaining tooth structure adequate for a conservative* non-metal restoration?
    • No  gold onlay
    • gold crown
    • PFM crown
    • zirconia crown
    • lithium disilicate-reinf. g-c crown
    • Yes  next question…
    • Can the tooth be isolated with rubber dam?
    • No  gold inlay/onlay
    • Yes  next question…
    • Will the isthmus width be less than one-half of the intercuspal distance?
    • Yes  direct composite
    • No  next question…
    • Will the restoration’s final occlusal thickness be less than 2 mm?
    • Yes  lab-processed composite resin
    • No  lab-processed composite resin
    • glass-ceramic
    • Other considerations:
    • Bruxer?
    • Severity? Active? Nightguard compliance?
    • Caries Risk Status?
    • Consider transitional restorations (e.g. glass ionomer) for high-risk patients
    • Anteroposterior Tooth Position
    • Further posterior  higher biting forces
    • Enamel Margins
  99. Survival of all-ceramics
    • No statistically significant difference in the clinical outcome…”
    • “However, …technical problems, such as fracture of veneering ceramic, tended to occur more frequently in the zirconia-ceramic groups.
  100. Direct composite veneer –
    • Indications:
    • Localized corrections on individual teeth
    • Diastema closure
    • Class IV
    • Patient is child or adolescent
    • Provisional treatment (medium/long-term)
    • Financial considerations
  101. hue
    color itself
  102. chroma
    • intensity
    • Low chroma  “weak”
    • High chroma  “highly-saturated”
  103. value
    • brightness of the color
    • High value = brighter (more white)
    • Lower value = darker (more gray)
    • Value of 0 = black
    • Value of 1 = white
  104. ____ is the most important color variable in dental shade selection!
    Value/Brightness
  105. Secondary Optical Properties -
    Translucency, Opacity, Opalescence, Iridescence, Fluorescence, and Surface Glos
  106. Color Influenced By
    • Characteristic of the light source
    • Degree which the object absorbs, transmits, reflects and scatters light
    • Environment where the color is observed
    • Human visionÿlight radiated from the objectÿmodified by human perception
  107. Opacity
    • impenetrable by light
    • reflective – neither transparent or translucent
  108. Transparency
    capable of transmitting light
  109. Translucency
    diffused transmission of light
  110. rods
    perceive value
  111. cones
    chroma, hue
  112. Standardized light source (for industrial color measurement)
    • 5000° K
    • CRI 98 (Color Rendering Index)
  113. Recommended lighting for accurate shade taking in dentistry:
    • 5500 ° K
    • Replicates northern natural midday daylight
    • balances all hues in the spectral curve
    • Working distance: 12 to 15 inches
    • Arm’s length
    • Appropriate environment
  114. Metamerism
    • Objects that appear similar under one condition but different under another.
    • i.e., an object appears to be different colors when viewed under different light sources
  115. Key Optical Properties of Teeth
    • Fluorescence: Emission of visible light upon exposure to fluorescent light
    • Dentin >> Enamel
    • Opalescence: Ability of a translucent material to…
    • appear blue in reflected light
    • appear red-orange in transmitted light
    • Translucency
  116. Vita Classic
    • A = Orange
    • B = Yellow orange
    • C = Grey orange
    • D = Brown orange
    • 70% will be A
    • 20% will be D
    • 10% will be B or C
    • Choose Hue, Chroma, Value
  117. Vita 3D
    • #-value (1-5)
    • Letter- Hue (L,M,R)
    • #-chroma (1-3)
    • Choose Value, Chroma then Hue
  118. Bleached teeth
    no hue, chroma only VALUE
  119. tooth 1/3rds color
    • gingival: high chroma, opacity
    • middle: high value, less chroma
    • incisal: high transluceny, lower value
  120. photographs for color
    • perpendicular: textures
    • 15-20degrees: color
    • 6-8 teeth
    • Tab at same angle as teeth
    • Tab as close to teeth as possible

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