Milady Standard Fundamentals Of Esthetics
Fundamentals Of Esthetics

Esthetic Rehabilitation in Fixed Prosthodontics, Volume 1 Esthetic Analysis: A Systematic Approach to Prosthetic Treatment Author(s)/Editor(s): Fradeani, Mauro Price: $ 258.00.
Radif: Title: Fundamentals of esthetics Author: Claude R.Rufenacht Location: Quintessence Nasher: Chicago Year: ۱۳۸۰. Shomareh Rahnama: 535 Keywords.

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1 Esthetic Crown Lengthening for Maxillary Anterior Teeth CE 5 Abstract: In the maxillary anterior region, the gingival labial margin position is an important parameter in the achievement of an ideal smile. The relationship between the periodontium and the restoration is critical if gingival health and esthetics are to be achieved. Periodontal therapy is a necessary and useful adjunct when any anterior restoration is undertaken. Anterior surgical crown lengthening may be undertaken to avoid restorative margin impingement on the biologic width. Crown lengthening is also used to alter the gingival labial profiles. This article discusses the esthetic parameters of ideal gingival labial positions and presents a classification of crown-lengthening procedures and the procedure for a two-stage crown-lengthening technique. The two-stage crownlengthening technique is surgically precise because healing is predictable. Dentistry has undergone a significant evolution in the last 2 decades. Sophisticated advances in the development of newer restorative materials and techniques have led to an unprecedented improvement in esthetic rehabilitation. It is no longer enough to merely replicate lost tooth structure. Patients demand and expect anterior rehabilitations to be esthetic. There is a tremendous focus on cosmetics today. One has only to gaze through magazine advertisements to see the emphasis that is placed on being attractive. Dentists are blessed with the unique ability to not only improve patients health but also enhance their attractiveness. The relationship between a person s physical appearance and his or her self-esteem is well documented 1,2 (Psychology Today, November, , 1973). Studies have shown that a person s face is the prime source of determining physical attractiveness. 1 Patients have stated that their teeth have the greatest impact on improving their physical appearance, and hence self-esteem. Therefore, dentists play a significant role in helping to improve their patients psychological health. Dentists are called on to provide restorations that are in harmony with the lips, the face, the adjacent teeth, and a healthy periodontium. Until recently, the scope of esthetic rehabilitation was limited to a close replication of tooth structure on a healthy periodontal foundation. In the past, periodontal therapy was aimed primarily at the elimination of disease, sometimes at the expense of esthetics. However, the scope of periodontal therapy has expanded. The primary goal remains to maintain the dentition with a healthy intact dentogingival unit. However, periodontics has now entered the age of periodontal plastic surgery. 3 Many periodontal therapies lead to esthetic amelioration of the dentition. These techniques allow for the ability to cover denuded roots, correct localized alveolar defects, regenerate bone, increase the amount of keratinized gingiva, enhance papilla reformation, and alter dental gingival levels. The preservation of a sound periodontium remains the sine qua non of a successful esthetic and functional restoration. A thorough knowledge of the normal anatomy and the interplay between the restoration and the periodontium is essential to achieve a predictable successful esthetic rehabilitation of the smile when prosthetics are planned in the maxillary anterior sextant. Communication between the restorative dentist and periodontist is essential in Michael Sonick, DMD Assistant Clinical Professor of Surgery School of Medicine Yale University New Haven, Connecticut Assistant Clinical Professor of Periodontics School of Dental Medicine University of Connecticut Farmington, Connecticut Private Practice of Periodontics and Dental Implants Fairfield, Connecticut Learning Objectives: After reading this article, the reader should be able to: describe the indications for crown lengthening in the maxillary anterior sextant. discuss the parameters of dental gingival labial relationships to achieve esthetics and harmony. determine how to position the restorative margin so the biologic width is not violated. explain the indications for the variety of crown-lengthening techniques available. Vol. 18, No. 8 Compendium / August

2 Figure 1 A clinical illustration of periodontal health and ideal esthetic gingival balance. Figure 2A The preoperative view of uneven, dissimilar gingival margins. Figure 2B Postoperatively, gingival symmetry and a more esthetic appearance are evident. Figure 3A The preoperative view of older anterior crowns. Note the gingival recession and uneven gingival margins. The dental gingival position of the centrals is too incisal. The patient s left and right laterals are more apical in position than the centrals. 808 these cases. Periodontal therapy plays an important role in the esthetic rehabilitation of the maxillary anterior segment, especially if periodontal disease is present. If the periodontium is healthy, the role of periodontics in smile rehabilitation is limited to crown lengthening and gingival augmentation. Many indications for clinical crown lengthening exist. These include caries removal, increasing crown length for restoration retention, restoration of the tooth without violating the biologic width, and esthetics via an alteration of the gingival labial profile. This article introduces a two-stage crownlengthening technique. The focus will be on the maxillary anterior sextant. The esthetic parameters and biologic rationale must first be discussed before the technique is elucidated. Esthetic Parameters of the Periodontium The gingival labial position is but one of a few factors that can contribute to an esthetic smile. The evaluation of a smile should include an analysis of the amount of gingival display when the lips are parted. The smile is dynamic and variable and changes with age. Aging leads to a decrease in the amount of maxillary central incisor display when smiling. 4 Depending on the relationship of the upper lip to the cervical margin of the maxillary central incisors, 5 a smile is one of three types: high lip line, low lip line, and medium lip line. The medium lip line is felt to be the most ideal, harmoniously displaying the dental and gingival elements in proportional symmetry (Figure 5H). A low lip line is rarely a problem for the restorative dentist. In fact, it often serves as a drape for imperfect dental relationships and dentistry. A high lip line, which displays a disproportionate amount of gingival tissue, can sometimes be altered if the clinical crowns can be lengthened. This is possible if there is excess gingival display, as in delayed passive eruption, or if the teeth will be restored and the dental gingival relationships reestablished at the new dental gingival junction. This is dependent on tooth length, incisal edge position, and the functional occlusion. Healthy, esthetic gingival tissues should be pink in color and firmly bound down to the necks of the teeth. The surface texture of the gingival tissues is stippled, with an orange-peel appearance. The interdental papillae extend from the free gingival margin and should be firm and knife-edged. They should fill the gingival embrasures to the contact point (Figure 1). Care should be taken to avoid loss of gingival papillae in all periodontal and restorative procedures because they are difficult, if not impossible, to re-create after being destroyed. The gingival zenith is located distal to the long axis of the tooth on the labial surface of

3 the maxillary central incisors and canines. In contrast, the maxillary lateral incisors have a symmetrical gingival height of contour with the gingival zenith at the midline of the labial tooth surface 5-7 (Figure 1). As stated earlier, the gingival height of contour ideally follows the contour of the upper lip. Closer inspection reveals that the gingival height of contour of contralateral teeth should be symmetrical. The height of contour of the central incisors should be symmetrical and at a level coincident with the

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