Practical Applications
A Dental Esthetic Checklist Treatment Planning Est Esthet het c Joseph Jos eph R. Greenbe rg, DMD ^ and Abstract:
ere dith
dental esthetic checklist form for m has bee introduced
entist en tistry ry
. Bogert, mig ht include ; another another popular esthe esthetiticc checklist includes includes
for use use in the diagnostic diagnostic w ork-up of patie nt accepte for
factors.' However, sources in the dental literature literature consistent-
treatment in an Advanced Education in General Dentistry
ly describe tbese seven bas basic ic criter ia
checklist, divided into seven basi basi criteria, is program. The checklist,
treatment results. The correct correct initial identification of these
not a complete list of all possible categories and nuances
items does not limit th practitioner from pursuing more
that an esthetic restorative assessment assessment migh t include . The
detail; instead, this checklist is an introductory organizer
correct initial identification of these criteria does does not lim it the
that invites further exploration. In the authors' experience,
dentist from pursuing more detail; in fact, this checklist is an
use of this form
prompted students to broaden their
introductory organizer organizer that invites invites further exploration, in th
visions from purely
dental/periodontal focus to one oness th at
authors ' experience, experience, the
emcomp emc ompas asss lip , cheek, cheek, and tongue configurations; smile; fa-
of this form prompts the the student
essential to successful
to broaden hi or her vision vision from purely a dental/pe riodon-
cial features; features; and related related planes planes of sym metry. Th is a pproach
focus to one that encompasses lip, cheek, and tongue
directs directs the dental ttreatment reatment p lan toward the additiona l goal
ta
configurations; smile; facial features; and related planes planes of symm etry. This approach directs directs the dental trea tme nt plan toward the important important additional goal of dentofacial harmony.
of dentofacial harmony. The "Dental Esthetic Checklist for Treatment Planning" displayed in Table 1.
previous previous artic le' defined and explained
tbe facial and dental term inology used used in the first three facAdvanced Education i n Genera objective object ive o the Advanced
tors, but a discus discussio sion n of supp orting dat is pertinent here
Dentistry Program at the Kornberg School of Dentistry is to elevate elevate the conceptual and technical
CHECK POINT 1: DM = FM
treatment standa standards rds of its students. students. Fundam ental to the resi-
The value of aligning the maxillary dental midline (DM) to
dents' patient treatment expe experi rience ence is thorough examination,
the patient's patient's facial facial
diagnosis, diagn osis, and treatment planning. Recent pub lications asse assert rt
removable removable prosthodontics prosthodontics literatu re.'"''The first text on dental
that the face is the first view requiring assessment by
esthetics^ stated that "the midline should
dental
practitioner,' thus this is the initial assessment made by the residents in performing
work-up in
patient for treatment.
idlin e (F
is cited ith freque frequency ncy in the
perpendicular
to tb incisai and occlusal occlusal plane and parallel to tbe midline face. ce."" Chiche and and Pin ault' wrote, "H arm onious faci facial al the fa
A dental esthetic checklist form, divided into seven basic
features are more symmetrical close to the facial facial midline and
criteria, ba bass been been introd uced for us in tbe diagnosti diagnosticc wo rk-
more asymm etrical etrical away from it." Spear'' reported that, in
up of
smile design, the starting poin t o f the esthe esthetiticc treatmen t plan
patient accepted for treatment in th thee program. This
checklist is not a complet complete e list of all th possible categories categories
statee that is the facial midline. Morley an Euban k'" stat
and nuances tbat
approach to locating the FM requires two refere reference nce p oint s:
dental estbetic restorative assessment
practical
'Clinical Professor of Restorative Restorative D entistry and Course Course Director, Advanced R estorative estorative Dentistry, The Kornbe rg School of Dentistry at Temple University, Ph iladelphia, Pennsylvania; Pennsylvania; Clinical Professor Professor of Periodontics, The University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania
Greenbera and Boaert Table 1: Dental Esthetic Checklist
for Treatment
Planning
Purpose:
To emphasize certain key factors in the comprehensive dentofacial examination, leading to diagnosis and treatm ent plannin g. Note: Fac al symmetry should be a key driver of the dental esthetic treatment plan.
Terminology:*
FM DM
1.
FM?
2. DV
FV?
3. DH
FH?
Facial Midline Dental Midline
D
FV = Facial Vertical Axis DV Dental Vertical Axis
N
(Measure and record/sketch discrepancy).
Y
N
(Measure and record/sketch discrepa ncy).
Y
N
(Measure and record/sketch discrep ancy).
FH DH
Facial Horizontal Dental Horizontal
. Are both maxillary central incisors equal ¡n position, symmetry, color/shade; and are they located at: FM/FV/FH? Do the tooth proportions and composition follow the rules of biometrics?' D Y D 5. Does the incisai edge line the maxillary anterior teeth follow the superior contour edge If not, please describe sketch.
the lower lip?
6. Does the incisai edge line form an "attractive" (convex, "gull-wing," or straight) edge pattern? Describe the relationship of lip aperture to the dental com position in "wid e sm ile," have pa tient b ite tightly and say "E ." (Check one.) of gingival display apical to cervical gingival margins). D High lip line smile (> U Normal lip line smile (0 to 3 m to 4 of gingival display). D Low lip line smile (lip covers all gingiva and/or maxillary anterior). 7. Profile and Phonetic/Speech Evaluation: a. Examine relationship of anterior teeth to the patient's facial outline fro m a profile perspective. Record your observations. b. Have the pa tient repeat the " F" and then "V" sounds to test proper pos itioning of the maxillary incisai edges. Note your findings. c. Have the patient say the "S" sound (can use words such as "Mississippi") while seated upright to evaluate occlusal vertical dimension and freeway space. Note your findings. •Greenberg and H o'
Figure 1 and Figure
'Chu^"
This patient's smile view showed complete fixed upper porcelain-fused-to-rnetal (PFM) dental restorations
with DM approximately centered to Cupid's Bow. The full-face sm ile view revealed a significant discrepancy betw een DM a nd FM. In this case, Cupid's Bow was not a reliable reference
to
FM . This aspect
the treatme nt result wa approved in advance by the
patient during the provisional restoration phase.
the nasion (a point between the eyebrows) and the base of the
of the populati on." The mandibular DM is either in motion
philtrtim (also referred to as Cupid's Bow). A line connecting
during function or covered by the maxillary teeth at rest or in
these two landmarks should locate the FM and also determine
smile. In 7 5% of the population, it does not coincide with the
the direction of the midline; this factor is referred to as facia
maxillairy midline,'^ thus the mandibular dental midline is not
vertical axis (FV) on this dental esthetic checklist.
usually visually important in esthetic dentistry."
The maxillary DM is the impor tant visual dental land-
The importance of aligning DM and FM in dental esthetic
Practical Applications
Figure 3 This patient had dental crowns on her maxillary
Figure 4 New zirconia-based, all-ceramic, full-coverag
central and lateral incisors that were located at DM = FM
crowns on the patien t in Figure 3 wi th corrected
bu t displayed a vertical axis discrepancy such tha t DV was
vertical axes.
not c ongruent
ith
V. Root caries was foun d aro und the
margins of these crowns, necessitating their replacement.
Figure 5 This patient's dental restorations revealed a
Figure 6 Smile view of the patient in Figure 5.
marked discrepancy between DH and FH.
Figure 7 New complete upper and lower fixed composite-
Figure 8 Smile view of the completed restorations.
fused-to-gold dental restorations for this patient with DH in harmony w ith FH
su ^e ste d that neither dentists nor laypersons notice a difference
reference point as previotisly described. By contrast, a more
in DM to FM deviations of up to 4 mm.
recent Web-based stud y'''w itb a larger sample size (2185 valid
his study of altered
photo graph ic images of natural smiles used only on e referenc
responses) used altered images of natural dentitions with full
point—Cupids Bow—and displayed no facial structures be-
faces side by side. This stud y found strong preferences
yond the upp er and lower lips. The patient used for this section
midline shifts at 3 m m. W itho ut a full-face reference, one m ay
of the article did not seem to have a sharply defined Cupid
not be truly be assessing the impa ct of dental com position varia-
ai ns
Greenberg and Bogert Flores-Mir et al"" suggested that laypersons naturally
CHEC!KPOINT4:
höfdi maxillary central incisors equal in position,
see dental esthetics as part of overall facial esthetics unless
Ar
intentionally directed to a close-up view of the dentition.
symmetry, color/shade; and are they located at
Pattoff and Ozar'^ wrote that although the expertise of the
FM/FV/FH? Do the relative tooth proportions
professional alone is considered sufficient to determine
and specifications follow the rules of biometrics?
if an oral health need has been met, in esthetic dentistry
Although naturally occurring maxillary central incisors do
it is the patient's judgment alone that is sufficient to de-
not alwîays measure the same in width and length, it is still
termine if a result is appropriate. If the dental profession
recommended to strive for a matched pair of central incisors
accepts these two articles as evidence based, it may wish
at FM = DM, FV = DV, and FH = DH when fabricating
to consider inclusion of the dentofacial examination as a
maxillaiy anterior dental restorations.' These pairs anchor
component of diagnosis and treatment planning in the
the cerjtral symmetry of the face to the dental composi-
dental school curriculum. Similarly, if patients naturally
tion, Which is a universally recognized feature of physical
see the full face and view their teeth and smile esthetics as
attractiveness.'^''^ Kokich et al concluded that asymmetric
part of this whole, then full-face images should become
alterations make teeth more unattractive not only to dental
standard in professional presentations and publications on
professionals but also to laypersons.^'
esthetic dentistry.
CHECK POINT 2: DV = FV DM should coincide with FM whenever possible. When DM = FM cannot be achieved, it is still highly desirable for the dental vertical axis (DV) to parallel the facial vertical axis (FV).'2 " This is referred to as DV = FV. It is possible but undesirable to have a correctly located DM with an incorrect DV. Any canted DV in either a restored or natural dentition is considered unattractive'" (Figure 3 and Figure 4). Figure
CHECK POINT 3: DH = FH The interpupillary line, ophraic line (eyebrows), and commissural line impart an overall sense of harmony and horizontal perspective to the esthetically pleasing face." None
This patient sought treatmen t for color correction
of her maxillary lateral incisors. The right lateral incisor was porcelain veneer and the left one was the pontic of an
all-ceramic, resin-bonded bridge, which had debonded on numerous occasions and wou ld be replaced wi th an etched PF resin-bonded prosthesis."
of these three anatomic landmarks absolutely defines the facial horizontal 100% of the time, but it is recommended to use them as general reference planes and then finalize the facial horizontal (FH) determination as perpendicular to the already determined FV. The incisai edge line (incisai plane) of the maxillary anterior dental composition and the buccal cusp tips of any posterior teeth on display in wide smile should be symmetrical to the FH plane (Figure 5 through Figure 8). There is considerable agreement for the esthetic importance of dental horizontal (DH = FH) among patients and dentists,^''^'*'"*"^'"'^" yet it is often difficult to record the visually apparent FH using functionally oriented dental
Figure 10 Closer evaluat ion using th e d enta l esthetic check-
articulators."" Supplementary devices now are available to
list also revealed unequal gingival margins and unattractive
dentists to transfer FH position to the dental laboratory
overall composition. The patient desired trea tment of
Practical Applications
Figure The Proportion Gauge was used to analyze to oth proportion, revealing the need for crown lengthening of the right central incisor to achieve a naturally attractive proportion of 78% wid th to length. It was decided that treatment would be accomplished by apical repositioning of the gingival margin.
Figure 12 The Proportion Gauge showed a need to lengthen the crown of the left central incisor also. Lengthening this crown in an incisai direction fulfilled the 78% w idth- tolength prop ortio n and satisfied Check Points 3, 4, 5, and 6, well. The method chosen to lengthen this tooth was direct composite resin bon ding . There were oth er possibl treatmen t modalities but only one correct treatmen plan.
Figure 13 The same patient after apical repositioning of the gingival margins for th e rig ht lateral and central incisor and incisai lengthening ofthe left central incisor.
Figure 14 A 6-month postoperative view of the gingival surgery. It also shows the appearance of the righ t lateral incisor porcelain veneer and the left lateral incisor po ntic of the etched P M resin-bonded retainer. N ote tha t the apical third of the pontic was fabricated to harmonize w ith the length of the right lateral incisor.
Practical Applications The Proportion Gauge (Hu-Friedy, www.hu-friedy.com) can be used to establish the 78 % width/length proportion of maxillary central incisors as described by Chu.^"* This gauge reliably produces visually attractive teetb based on data compiled from natural anatomic measurements. Biometrics'^'' is a recommended methodology to achieve pleasing upper and lower anterior tooth compositions true to natural dental anatomic specifications (Figure 9 through Figure 16).
CHECKPOINTS: Figure 17 This patient displayed lower lip asymmetry. The recom men dation o f Check Point 5 s to fo llow the H in such a situation, as presented here. A d ental com position tha t follow s a symmetrical lowe r lip contour can be seen again in Figure 15.
Does the incisai edge line of the maxillary anterior teeth follow the superior co ntou edge of the lower lip? There is general agreement that the incisai edge line of the maxillary anterior teeth (an im aginary line scribing th roug the incisai edges) should have an equidistant consistency to the superior contour edge of the lower lip." In cases in which the lower lip exhibits asymm etry, the recom me ndation s t follow the facial horizon tal axis as previously determ ined and disregard the lower lip (Figure 17).
CHECK POINT 6: Does the incisai edge line form an "attractive" (convex, "gull-wing," or s traight) edge pattern? Attractive incisai edge lines can be c onvex, "gull-wing," straigh t, or some combination of these— but never concave in a downFigure 18 The incisai edge line of this pa tient indicates an unattra ctive, concave patte rn. There are also discrepancies of DM to FM, DV to V, and DH to FH. Altho ug h the maxillary central incisors seem equal in size to each other, they we re not centered in the patient's face.
ward direction" (Figure 18 and Figure 19). While examining the incisai edge line and its relationship to the lips, it is a good time to note the relationship of the lip aperture to the dental display in "wide smile" and repose. T he patie nt usually will give his or her widest smile when asked to b ite tighdy a nd say "E."
CHECK POINT 7: Profile and Phonetic/Speech Evaluation Spontaneous clear speech
is extremely
impor tant to the patient.
Tbe "F" and "V" sounds can be used to determine correct maxillary incisai edge position. The "S" sound has been described to test for adequate freeway space when an alteration in occlusal v ertical dim ens ion is being considered."*' Current writings question the emphasis that orthodontists traditionally have placed on profile view and lateral cepha lom etFigure 19 The final tooth and dental implant-supported
ric analyses, but it is still important for tbe dentist to examine,
maxillary fixed prosthesis achieved a more convex incisai
relate, and doc um ent the profile view of the teeth, lips, and vis-
edge line. Corrections of DM to FM, DV to FV, and DH to FH also were achieved and the maxillary central incisors
ible periodontium to the facial complex.^'' Ackerman wrote that
were centered in the face as a result. The patient's lower lip
the future of dentofacial esthetic treatmen t p lannin g lies in the
was asym metrical to
clinician's ability to envision th e patient's desired 3-dim ensional
H so, s in Figure 17, the resto ration
Practical Applications hard tissues to produce this desired result. This science quickly is
9. Spear
F.
Th esthetic management of dental midline problems
evolving with the aid of new technology that produces 3-dimen-
with restorative dentistry. Compend Contin Educ Dent. 1999;20
sional images. As dentists learn to acquire, interpret, and share
(10):912-918.
these images with their patients, new standards for dentofacial
10 Morley J, Eubank J. Macroesthetic elements of smile design.y/)w
esthetic examination, diagnosis, and treatment planning may
Dent Assoc. 2001;132(l):39-45.
be established by the dental profession.
Ahmad I. Anterior dental aesthetics: dentofacial perspective. Br DentJ. 2005;199(2):81-88.
CONCLUSION
2.
ship of the dental midline to the facial median Wne. J Prosthet Dent.
The dental literature now states that ideally, a dentist's work
1979;4l(6):657-660.
should conform to the dental profession's standards for teeth that are properly shaped and colored within an individual
3.
A seven-point dental esthetic checklist that was developed
Orthod 1999;21(5):517-522.
14 Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental csthcúcs. J Esthet
for dentofacial examination, diagnosis, and treatment planning in an Advanced Education in General Dentistry program was presented. Its purpose is to guide the clinician, via the identification of an organized sequence of physical parameters recognizing major elements of dental composition and funaion
Dent. 1999;11 (6):311-324 5.
2002;14(2):97-106.
smile aesthetics in dental and facial views./ Orthod. 2004;31 (3): 204-209. 7.
PatthofFD, Ozar D. Need vs desire. Professional judgment in esthetics. AG
8.
pleasing and attractive and that will flilfill the professional obli gations of the dentist to these newly published ethical standards.
Rashid RG. Public preferences for anterior tooth vari-
16. Flores-Mir C, Silva E, Barriga MI, et l. Lay persons perception of
be a harmonious integration of displayed dental component with facial structures that patients and dentists will recognize as
Rosenstiel
ations: web-hasedstudy./ßf/ieiÄßtorDOTf.
and placing these elements in a symmetrical relationship withi the facial complex, to a desired end point. This result should
Johnston CD, Burden DJ, Stevenson MR. The influence of dental midline discrepancies on dental attractiveness ratings. EurJ
patient's complete dentition and balanced with the patient's gingival and facial features.^
Miller EC, Bodden WR Jr, Jamison HC. A study of the relation-
Impact. 2007;35(8):32-35.
Beyer JW, Lindauer SJ. Evaluation of dental midline position. Semin Orthod 1998;4(3):146-152.
9.
Roach RR, Muia PJ. Communication between dentist and technician: An esthetic checklist. In: Preston JD, ed. Perspectives in
ACKNOWLEDGMENTS
Dental Ceramics. Proceedings of he Eourth International Symposium
Dental laboratory technology by J. Lee (Figures 2, 4, 14, and
on Ceramics. Chicago, IL: Quintessence; 1988:445.
19), R. Rafetto (Figure 8), and A. Canterbury (Figure 17).
20. Chiche GJ, Aoshima H. Functional versus aesthetic articulation of maxillary anterior restorations. Pract Periodontics Aesthet Dent.
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