Fundamentals Of Esthetics Rufenacht Pdf Writer
Recently, the request of patients is changed in terms of not only esthetic but also previsualization therapy planning. The aim of this study is to evaluate a new 3D-CAD-CAM digital planning technique that uses a total digital smile process. Materials and Methods. Study participants included 28 adult dental patients, aged 19 to 53 years, with no oral, periodontal, or systemic diseases. For each patient, 3 intra- and extraoral pictures and intraoral digital impressions were taken. The digital images improved from the 2D Digital Smile System software and the scanner stereolithographic (STL) file was matched into the 3D-Digital Smile System to obtain a virtual previsualization of teeth and smile design.
Then, the mockups were milled using a CAM system. Minimally invasive preparation was carried out on the enamel surface with the mockups as position guides. The patients found both the digital smile design previsualization (64.3%) and the milling mockup test (85.7%) very effective. The new total 3D digital planning technique is a predictably and minimally invasive technique, allows easy diagnosis, and improves the communication with the patient and helps to reduce the working time and the errors usually associated with the classical prosthodontic manual step. Introduction In recent years, the concept of what makes a smile beautiful has changed significantly ,. Nowadays, patients expect complex functional rehabilitations that are esthetically appealing –.
Fundamentals of Esthetics. Esthetics in dentistry second edition volume 2 esthetic problems of individual teeth missing teeth malocclusion special populations ronald e. Ebook download as PDF File (.pdf), Text File (.txt) or read book online.
An important goal in prosthodontic is to use minimally invasive treatment to improve the appearance of the smile – as a way to valorize the entire image of the patient while maintaining the health and function of teeth and soft tissue ,. Porcelain laminate veneers (PLVs), minimally invasive solutions to dental esthetic problems, have the most long-term success , –. There are a number of stages in rehabilitative dental treatment, from making the impression and developing the model to creating the diagnostic wax-up and to constructing the laboratory mockup. The planning associated with creating a mockup is a very important as it affects patients' understanding of the expected result ,. Whether the patient is happy with the overall treatment depends on how similar the prosthesis is to the mockup ,. The shape of the teeth, the adaptation of the prosthesis, and the size and the color of the new elements in relation to the soft tissue, lips, and the whole face are very important in the decision-making. A large number of errors can occur at the various stages of the traditional prosthetic workflow, each stage requires a transfer of two-dimensional and three-dimensional (3D) data between operators.
As computer-aided design and computer-aided manufacturing (CAD/CAM) and new materials are leading to a paradigm shift in what many practitioners regard as standard care for patients, a priority is to drastically reduce operator error. The aim of this research was to evaluate new total 3D digital smile planning technique (3D-DSP) used in the previsualization stage prior to milling poly(methyl methacrylate) (PMMA) mockups in the process of creating PLVs using a CAD/CAM system. Distribution of porcelain laminate veneers according to location.
After radiological, phonetic, and static and dynamic occlusal evaluation, each patient had three intra- and extraoral digital images taken while wearing special eyewear (Digital Smile System Srl, Italy) (Figures and ). An intraoral scanner (Scanner 3D Progress, MHT, Italy) was used to get intraoral digital impressions of the maxilla and mandible arches in open and occlusal states. All the digital images, obtained from the processing of the pictures into the software 2D-Digital Smile System (Digital Smile System Srl, Italy) and the STL file from the intraoral scans, were combined into the 3D-Digital Smile System (EGS Srl, Italy) to display the patient's teeth and, from this, a virtual design of the potential dental prosthesis was created. When the patient agreed to this virtual 3D view of their planned-for prosthetics, a PMMA mockup (Bredent Srl, Italy) was milled using a CAM system (Zirkonzahn Srl, Italy).
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Each mockup was tested in the patient's oral cavity to make sure they would consent to the esthetic therapy and be satisfied with the end result. The newly milled mockups, cemented using spot-etch technique , , were used to guide the position of the prosthetics and maintain the margins on the enamel surface of the teeth –. The double cord techniques with the intraoral scanner (Scanner 3D Progress, MHT, Italy) was used to make all the definitive impression of the prepared teeth. The PLVs (IPS e.max System, Ivoclar Vivadent Srl, Italy) were produced using CAD/CAM technique (Zirkonzahn Srl, Italy). A total of 78 Variolink veneers (Ivoclar Vivadent Corp., Liechtenstein) and 30 Clearfil Esthetic Cement veneers (Kuraray America Inc., USA) were cemented onto vital teeth. Each patient had final intra- and extraoral digital images taken (Figures and ).
Follow-up took place after 2 years. Distribution of failures according to preparation design. Patients responded to a questionnaire to determine their satisfaction with the digital smile design planning and the test in the form of the mockup. They graded both the planning and the test as effective, very effective, or ineffective. For the digital smile design previsualization, with visual analogical scale (VAS scale), 18 (64%) of patients found it very effective and 10 (36%) effective; 24 (86%) found the milling mockup very effective and 4 (14%) effective. Discussion In all prosthodontic aesthetic treatment, the accurate design planning and the basic communication phase with the patient play a crucial role in the therapy. The best previsual means most widely used as a measure of explanation with a patient is the therapeutic planning, associated with the creation of a mockup ,.
With contemporary digitalized techniques, it is possible to redesign a patient's smile ,. Effective previsualization followed by a mockup is the ideal way to explain changes to a patient and receive their approval –. Traditional “analogical techniques” are based on a planning process that involves radiological and clinical evaluation, intra- and extraoral photographic analysis, static and dynamic occlusal evaluation, and traditional impressions.
The more traditional techniques that use the free-hand “composite technique” before the wax-up do not evaluate the design of the smile ,. A secondary evolution of digital prosthetic planning is limited to bidimensional digital work flow and requires, after digital smile design protocol, the stone model, the manual processing of a laboratory diagnostic wax-up, and the printing of the classic mockup in the patient's oral cavity through the use of silicone keys. In traditional planning techniques, the data transfer from virtual design to laboratory is difficult and potentially full of errors because it uses a manual process to obtain the computer design of canine zenith lines for the laboratory stone model.
This manual process is necessary to transfer all the measurements of the teeth to the new smile project design. Another difficult and unpredictable process is the mockup printing in the patient's oral cavity with a silicone mask (made on a wax-up) –. Our new planning technique allows a new totally digital and CAD-CAM process, from the initial photo shoot to CAD/CAM-milling mockup, to reduce the errors usually associated with the classical manual steps and to improve the accuracy of the prosthetic procedure. All digital data transfer from the clinical 3D planning to the laboratory CAD/CAM process is simpler, faster, and more predictable. However, having photographs plays a crucial role: the patient-approved virtual smile is used to guide the final design of the teeth, which are usually made with the CAD/CAM process. Conclusions A 2-year follow-up of prosthetic PLVs created using the new total digital smile planning technique in vital teeth in the esthetic zone showed that it is possible to obtain excellent results in both functional and esthetic rehabilitation and high patient satisfaction. The new procedure also reduces the amount of time spent in the clinic and laboratory, increases the predictability of data matching to build CAD/CAM-milling mockups, reduces trauma caused by handling hard dental tissues, and improves accuracy and reproducibility of the final mockup.
The total new digital smile planning technique is minimally invasive and facilitates diagnosis, improves communication with the patient, reduces processing times, and increases predictability of the results with very little discomfort and very high esthetic final results. The present study has limits, such as the limited number of patients enrolled: further studies on a larger sample of patients are therefore needed to confirm our present results.
. The shape, length and width of maxillary anterior teeth are open to interpretation, including mathematical, physiological and psychological. Tooth alignment, in three dimensions, creates a pleasing tooth-to-tooth progression. The position of the teeth in the dental arches also ensures correct phonetics and occlusion.
ANTERIOR DENTAL AESTHETICS. Historical perspective. Facial perspective. Dento-facial perspective.
Dental perspective. Gingival perspective.
Psychological perspective.Part 6 available in the BDJ book of this series. The morphology of maxillary anterior teeth is a fusion of the three basic shapes: circle, square and triangle. These shapes are analogous to the primary colours (red, green and blue), from which any colour can be created. Similarly, any shape can be created from a circle, square or triangle. The unique composite morphology of the teeth allows diversity and individuality. Essentially, no two teeth are ever alike, but all share the same geometric building blocks. This configuration has allowed nature carte blanche to produce inimitable shapes based on only three variables.
Emphasising one shape and suppressing the others, has promoted manufacturers of artificial teeth for dental prostheses to classify teeth as circular, rectangular or triangular. The shape of the maxillary anterior teeth has been the subject of numerous studies. The most prominent are by Williams and Frush and Fisher., Williams proposed that the shape of the central incisor was the inverted frontal view of the face, while Frush and Fisher suggested that sex, age and personality related to the contour of the anterior dental segment. Williams' theory was invalidated by subsequent studies. The Frush and Fisher concept is concerned with the dominance of the central incisors and their wear in advancing years. It is worth noting that the chronological age of a patient might not coincide with the dental age.
In cases where a patient has pronounced wear, either by local or systemic causes, the dental age may be greater than the chronological age. The opposite is evident for older individuals with sharp incisal edges and pronounced incisal embrasures, conveying a youthful dental appearance. Other theories have proposed correlating tooth shape with skeletal and soft tissue landmarks, but these ideas have proved inconclusive. The shape of teeth is genetically determined and the prosthodontist should, if possible, obtain pictures of a patient's relatives before determining the shape of the definitive prosthesis.
If no records are available, the points to consider are age, sex, race, and personality. For example, youthful teeth are sharp, having unworn incisal edges; with the central incisors dominating the composition, and in harmony with the laterals and canines.
The reverse is true for an older dentition, ie blunt incisal edges and wear and attrition without conclusive dominance of the maxillary central incisors. Sociologically, stereotypes are readily recognised and associated with specific individuals.
These divisions are culturally specific and relevant to a particular country or demographic locality. For example, it is generally recognised that females display curvaceous features (both facially and bodily), devoid of sharp line angles. On the other hand, masculinity is associated with ruggedness and sharp line angles. The process of transposing these gender variations onto the shape of the teeth ( and ) is a concept termed morphopsychology (see part 2: Facial perspectives). Finally, personality is significant for perception of an individual in society. A gregarious, vivacious persona is linked to an effervescent personality, while a sombre, reclusive character is perceived as bland and unsociable. Once again, these stereotypes are influenced by upbringing, intellect, culture, and theology.
Linking these traits to dental morphology is conforming purely to society's perception of an individual. Making teeth, which are bright, bulbous, and prominent, are appropriate for an outgoing person. Conversely, teeth that convey subtlety with a lower value, and hence are less conspicuous, may be more suited to an introvert. Personality traits are discussed further in the sixth and final article entitled Psychological perspective, which looks at the psychological influence of our cerebral perception to the dentition. No definitive value for the w/l ratio exists and experts dispute its value.
The mesio-distal width is more important than the inciso-gingival length and the former measurement has attracted much debate. Research has focused on measurements of extracted teeth, racial and gender differences, together with facial landmarks such as the bizygomatic width. House and Loop postulated that the mesio-distal measurement of the central incisor was 1/16 of the bizygomatic width. Other studies have also sought to assign geometric values for the mesio-distal width of the centrals, eg 1/16 of the face height or the width of the iris. There are two schools of thought regarding the size of the maxillary central incisors. The first is by Rufenacht who proposed morphopsychological determination of an ideal proportion, and suggested that the width and length of the central incisor should be constant throughout life.
This view relies on the philosophical notion of eternal youth as described by French writer Robert Brasillach who said, 'in life only one youth exists and we pass the rest of our days regretting it'. While this statement may seem romantic, many regard it as sacrosanct and seek a myriad options to stave off our 'final destination'. Bearing this in mind the clinician's role is not to act as judge, but as a conduit for patients' desires. If a person seeks such an option, the dental team should try not to deny a patient's wishes. The second theory states that our bodies are in perpetual change throughout life. We are born small, become taller, and eventually lose height in advancing years.
Our skin has tone and suppleness in youth but becomes flaccid and dull as we grow older. The dentition is no exception to this transformation. When the central incisors erupt, they are pristine with defined incisal lobes, a textured surface roughness, bright enamel, with a smaller w/l ratio. During normal functioning, excluding the effects of disease, the incisal edges wear (resulting in a larger w/l ratio), surface texture becomes smooth, and the enamel dulls due to increased translucency. These processes are congruous with the ageing of the rest of the body.
Creating teeth with a youthful appearance is discordant in an older person and creates a sense of artificiality. The evidence behind each theory is inconclusive and each concept is still open to discussion. Furthermore, the overriding factor in any case is a patient's wish including their perception of themselves in society. Nevertheless, general guidelines are useful for creating a pleasing result. Firstly, the w/l ratio of the central incisor should range from 0.75 to 0.8, a value less than 0.6 creates a long narrow tooth, and beyond this number results in a short wide tooth.
Secondly, the central incisor should be the dominant element in the anterior dental composition. Lastly, the vertical overbite in relation to speech and anterior guidance needs addressing. Besides these fundamental principles, subtle variations can be introduced which account for gender, race, facial, morphopsychological, and psychological factors. The buccolingual thickness shows wide variance, ranging from 2.5 mm to 3.3 mm for the maxillary central incisors. The thickness is measured with a width gauge, at the junction of the middle third and incisal third of a tooth. For a crown, if a reading of more than 3.5 mm is apparent, then over-contouring of the prosthesis is suspected, usually because of under-preparation by the clinician leaving the ceramist inadequate room for the porcelain layer build-up, resulting in a bulbous crown. If the thickness of a tooth is less than 2.5 mm, elective endodontic therapy may be necessary to achieve the desired aesthetics.
In cases where a tooth is inclined facially or lingually, and the proposed prosthetic treatment is to simulate its location beyond 2 mm, interceptive orthodontic therapy may be mandatory. Having established guidelines for shape and dimensions of the maxillary anterior segment, and in particular that of the central incisor, the next point to consider is the relationship between incisors and canines. The tooth-to-tooth relationship frequently relies on the Divine (or Golden) proportion and dynamic symmetry, initially proposed by the ancient Greeks. In 530BC Pythagoras suggested beauty could be defined as an exact mathematical concept, which led to the Divine or Golden proportion (1/1.618=0.618).
Similarly, Plato proposed the Beautiful proportion (1/1.733=0.577) as the quintessential ratio for beauty. Both ideas stated that an object with these proportions had innate beauty.
The most widely used concept in dentistry is the Golden proportion — where S is the smaller and L the larger part: The uniqueness of this ratio is that when applied by three different methods of calculations, linear, geometric and arithmetic, the proportional progression from the smaller to the larger to the whole part always produces the same results. Lombardi and Levin have transposed this ratio to the maxillary anterior sextant. Other researchers have indicated that clinically the Golden proportion is not always evident and variations are often apparent. In one study, measurements of plaster casts of natural teeth revealed that only 17% conformed to the Golden proportion. This begs the question that if only some teeth conform to this rule, which ratio is prevalent for the rest of the population? Although the Golden proportion is invaluable as a starting point for aesthetic appraisal, the reality is that any ratio from 0.6 to 0.8 is aesthetically acceptable.
The salient points to consider are harmony, balance, morphopsychology, and psychology. Lastly, morphopsychological and psychological factors can influence the chosen ratio for the tooth-to-tooth relationship. For example, if the intention is to convey masculinity by choosing a larger recurring ratio in a small arch, a disto-facial imbrication of one or more teeth in the maxillary anterior segment resolves the predicament. Conversely, a mesio-facial imbrication conveys femininity with a narrow maxillary arch form.
To summarise, the paramount issue for gaining aesthetic approval in a composition is ensuring harmony and balance, irrespective of size or ratio. Another aesthetic marker is the axial inclination of the upper anterior teeth. Ideally, a mesial axial inclination seems to attract aesthetic approval, while a distal one conveys visual tension. One explanation why a mesial inclination, as opposed to distal one, invokes a sense of aesthetic approval is that the curvature of an object (convex or concave) is important to the way it is perceived.
Concavity conveys receptiveness and belonging, while convexity the opposite, eg pushiness and aggression. An example is a relaxed smile when the concavity of the maxillary incisal plane is parallel to the concavity of the mandibular lip. Both these concavities are perceived as welcoming and receptive, which after all, is the purpose of a smile. In a similar manner, mesial axial inclination forms a concave curvature, also conveying receptiveness and belonging. Further enrichment of the anterior dental segment is created by ensuring that the interproximal contact points coincide with the incisal edges, and the curvature of the mandibular lip, enhancing the cohesiveness of the dentofacial composition. Horizontal and vertical overbite depends on the inciso-gingival length of the anterior teeth (both maxillary and mandibular), the shape of the arches, and angulations of the teeth in the sagittal plane. In ideal circumstances, the maxillary central incisors are 12 mm long, perfectly aligned and the arch form is within the norm, with the mandibular central incisor 10 mm long.
In this case, the vertical overlap and horizontal overlap are 4 mm and 2 mm, respectively. Furthermore, with this ideal overbite and overjet, the occlusal vertical dimension (OVD) is 18 mm, measured from the gingival zeniths of the maxillary and mandibular central incisor. Once again, these utopian clinical presentations are rare. To establish a correct inter-arch relationship, the starting point is the location of the maxillary central incisor edge position with the lips at rest, and during a relaxed smile ( and ). During these two soft tissue positions, the incisal edges are assessed, and influenced by three variables. The first is aesthetics. Ideally, the maxillary incisal edges should be parallel to the curvature of the mandibular lip.
The second issue is to ensure that phonetics are not compromised. In the sagittal plane, when the 'f' and 'v' sounds are spoken, the buccal surfaces of the maxillary incisors should contact the inner or mucosal surface of the mandibular lip. If these teeth encroach on the cutaneous part of the mandibular lip, this indicates either an over-contoured, or bulbous restoration or incorrect tooth angulations. Lack of contact with the lower lip indicates shortened or incorrectly aligned maxillary incisors.
The 's' sound determines the vertical dimension of speech, characterised by an unimpeded edge-to-edge position of the maxillary and mandibular incisors. Finally, during a 'th' sound, the tongue should make contact with the palatal surfaces of the maxillary incisors. The teeth, as with the other perspectives of dental aesthetics, display variance and nuances, showing individuality in a given dentition.
This article has tried to present old and new concepts on tooth morphology, size and their relation to each other. In conclusion, no single aspect can be accredited with successfully arriving at the final shape and dimensions of the maxillary anterior teeth. The clinician and ceramist ultimately rely on their experience and observations, combined with patients' desires, for creating functioning and aesthetically pleasing prostheses. A new classification of human tooth forms with a special reference to a new system of artificial teeth. 1914; 56: 627. WJ Murchison D F, Broome J C. Esthetics: Patient perception of dental attractiveness.
Fundamentals Of Esthetics Rufenacht Pdf Writers
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