interdisciplinary management of ce anterior dental esthetics · illary dental midline. if the...

In the past 25 years, the focus in den-tistry has changed gradually. Years

ago, dentists were in the repair busi-ness. Routine dental treatment involvedexcavating dental caries and filling theenamel and dentinal defects with amal-gam. In larger holes, more durablerestorations may have been necessary,but the focus was the same: repair theeffects of dental caries. However, withthe advent of fluorides and sealants, aswell as a better understanding of therole of bacteria in causing both cariesand periodontal disease, the needs ofthe dental patient have changed gradu-ally. Many young adults who are prod-ucts of the sealant generation have littleor no caries and few existing restora-tions. At the same time, our image of

the value of teeth in Western societyalso has changed. Yes, the public stillregards teeth as an important part ofchewing, but today the focus of manyadults has shifted toward esthetics(“How can my teeth be made to lookbetter?”). Therefore, the formerly inde-pendent disciplines of orthodontics,periodontics, restorative dentistry andmaxillofacial surgery often must joinforces to satisfy the public’s desire tolook better.

This trend toward a heightenedawareness of esthetics has challengeddentistry to look at dental esthetics in amore organized and systematic manner,so that the health of the patient and hisor her teeth still is the most importantunderlying objective. But some existing

Interdisciplinary Management ofAnterior Dental Esthetics

Frank M. Spear, DDS, MSDFounder and Director

Seattle Institute for AdvancedDental Education

Seattle, Washington

Affiliate Assistant ProfessorUniversity of Washington

School of DentistrySeattle, Washington

Private PracticeSeattle, Washington

Vincent G. Kokich, DDS, MSDProfessor

Department of OrthodonticsSchool of Dentistry

University of WashingtonSeattle, Washington

David P. Mathews, DDSAffiliate Assistant Professor

Department of PeriodonticsSchool of Dentistry

University of WashingtonSeattle, Washington

Learning Objectives

After reading this article, thereader should be able to:

• explain the treatment planningsequencing concept of beginningwith esthetics and workingtoward biology.

• describe the steps to integratingfunction and esthetics whenassessment of esthetics isaccomplished first in thetreatment planning process.

• discuss how the decisions madein each individual assessmentcategory impact the eventualoutcome of the case.

Abstract:Background. Dental esthetics has become a popular topic among all disciplinesin dentistry. When a makeover is planned for the esthetic appearance of apatient’s teeth, the clinician must have a logical diagnostic approach thatresults in the appropriate treatment plan. With some patients, the restorativedentist cannot accomplish the correction alone but may require the assistanceof other dental disciplines.

Approach. This article describes an interdisciplinary approach to the diagnosisand management of anterior dental esthetics. The authors practice differentdisciplines in dentistry: restorative care, orthodontics and periodontics. However,for more than 20 years, this team has participated in an interdisciplinary dentalstudy group that focuses on a wide variety of dental problems. One such area hasbeen the analysis of anterior dental esthetic problems requiring interdisciplinarycorrection. This article will describe a unique approach to interdisciplinarydental diagnosis, beginning with esthetics but encompassing structure, functionand biology to achieve an optimal result.

Clinical Implications. If a clinician uses an esthetically based approach to thediagnosis of anterior dental problems, then the outcome of the esthetic treatmentplan will be enhanced without sacrificing the structural, functional and biologicalaspects of the patient’s dentition.

Key Words. Interdisciplinary dentistry; anterior dental esthetics; crown length;anterior tooth wear; gingival levels; crown lengthening; orthodontic intrusion;width-to-length ratio; resting lip level; diagnostic wax-up.

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6 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 4, 2006

Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. JADA 2006;137(2):160-9. Copyright © 2006 American Dental Association. All rights reserved. Reprinted with permission.

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dentitions simply cannot be restored toa more esthetic appearance without theassistance of several different dental dis-ciplines. Today, every dental practition-er must have a thorough understandingof the roles of these various disciplinesin producing an esthetic makeover,with the most conservative and biolog-ically sound interdisciplinary treatmentplan possible.

We have worked in such an envi-ronment for the past 20 years. Asprosthodontist, orthodontist and perio-dontist, we have belonged since 1984to an interdisciplinary study groupconsisting of nine dental specialists andone general dentist.1 We have metmonthly since that time to educate oneanother about the advances in each ofour respective areas of dentistry and toplan interdisciplinary treatment forsome of the most challenging andcomplex dental situations.

One of these interdisciplinary areasis esthetics. The purpose of this article is

to provide the reader with a systematicmethod of evaluating dentofacial esthet-ics in a logical, interdisciplinary manner.

Sequencing the Planning Process

Historically, the treatment planningprocess in dentistry usually began withan assessment of the biology or biolog-ical aspects of a patient’s dental prob-lem. This could include the patient’ssusceptibility to caries, periodontalhealth, endodontic needs and generaloral health. Once the biological healthwas re-established—through cariesremoval, modification of the bone and/or gingiva, endodontic therapy ortooth removal—then the restoration ofthe resulting defects would be based onstructural considerations. If teeth wereto be restored or repositioned, the func-tion of the teeth and condyles wouldbe of paramount importance in dictat-ing occlusal form and occlusal relation-ships, respectively. Finally, esthetics

would be addressed to provide a pleas-ing appearance of the teeth.

However, if the treatment planningsequence proceeds from biology to struc-ture to function and finally to esthetics,the eventual esthetic outcome may becompromised. Therefore, we proceedin the opposite direction: we start thetreatment planning process with esthet-ics and proceed to function, structureand, finally, biology. We do not leave outany of the important parameters; wesimply sequence the planning processfrom a different perspective. We choosethis sequence because the decisions madein each category, especially esthetics, willdirectly affect the decisions made in thecategories that are assessed subsequently.

Beginning With Esthetics in Mind

When beginning with esthetics, wemust begin with an appraisal of theposition of the maxillary central incisorsrelative to the upper lip (Figure 1). This

Figure 1 This man was concerned about the esthetic appearance of his maxillary anterior teeth (A). At rest, he showed about 4 millimeters of maxillaryincisal edge (B). In protrusive position, he had more than sufficient incisal length to disclude the posterior teeth (C). Because of a protrusive bruxing habit,his mandibular incisors were worn and positioned apical to the posterior occlusal plane (D). The gingival margins were located correctly and the preparationshad adequate ferrule (E). Therefore, the maxillary incisors were shortened to facilitate restoration of the mandibular incisors (F) and the maxillary incisors (G).Because the treatment was planned using esthetic principles, it was possible to improve the esthetic proportions of the teeth (H: before; I: after).

Vol. 2, No. 4, 2006 Advanced Esthetics & Interdisciplinary Dentistry 7

A

D

B

E

C

F

G H I

assessment is made with the patient’supper lip at rest. Using a millimeter ruleror a periodontal probe, we determinethe position of the incisal edge of themaxillary central incisor relative to theupper lip. The position of the maxillarycentral incisor can be either acceptableor unacceptable. An acceptable amountof incisal edge display at rest depends onthe patient’s age. Previous studies haveshown that with advancing age, theamount of incisal display decreases pro-portionally.2,3 For example, in a 30-year-old, 3 millimeters of incisal display at rest

is appropriate. However, in a 60-year-old, the incisal display could be 1 mmor less. The change in incisal display withtime probably relates to the resiliencyand tone of the upper lip, which tendsto decrease with advancing age.

If the incisal edge display is inadequate(Figures 2 and 3), then a primary objec-tive of interdisciplinary treatment maybe to lengthen the maxillary incisal edges.This objective could be accomplishedwith restorative dentistry,4 orthodonticextrusion5 or orthognathic surgery.6-8

Choosing the correct procedure will


Figure 2 This man had significant wear (A) of his maxillary anterior teeth. His incisal edges were positioned coronal to his upper lip (B) at rest. The max-illary posterior teeth were restored and not worn (C). To determine the extent of treatment, the desired incisal edge position was estimated on the basisof the existing posterior occlusal plane (D). The gingival margins were estimated by means of the desired width-to-length proportions of the anterior teeth(D). Then a diagnostic wax-up on mounted dental casts determined whether the correction could be made without orthodontics or jaw surgery (E,F).The gingival margins were relocated with osseous surgery (G,H). Postoperatively, there was sufficient ferrule with adequate sulcus depth (I ) to create ante-rior restorations with proper esthetic form ( J ). The final restoration established an improved occlusion (K) with enhanced anterior esthetics (L). Patientphotograph reproduced with permission of the patient.

A

D

B

E

C

F

G H I

J K L

If the incisal edge display is inadequate, then a primary objective of

interdisciplinary treatmentmay be to lengthen the maxillary incisal edges.

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depend on the patient’s facial propor-tions, existing crown length and opposingocclusion. If the incisal edge display isexcessive (Figure 1), then an objective oftreatment could be to move the maxillaryincisors apically by either equilibration,9

restoration,10 orthodontics11,12 or ortho-gnathic surgery.13 The decision betweenthese disciplines again will depend onthe patient’s existing anterior occlusion,facial proportions or both.

The second aspect of esthetic toothpositioning to be evaluated is the max-illary dental midline. If the midline is

deviated to the right or left, studies haveshown that midline deviations of up to3 or 4 mm are not noticed by lay peopleif the long axes of the teeth are parallelwith the long axis of the face.14,15 So per-haps the most important relationshipto evaluate is the mediolateral inclina-tion of the maxillary central incisors.Researchers have found that if the inci-sors are inclined by 2 mm to the right orleft, lay people regard this discrepancy asunesthetic.15,16 A canted midline can becorrected with orthodontics17 or restor-ative dentistry.18 Usually the decision


Figure 3 This man had traumatized his maxillary anterior teeth at a young age (A). These teeth were discolored (B), and the incisal edge was positionedonly one millimeter from the lip at rest (C). The maxillary and mandibular incisors were in an end-to-end occlusal relationship (D), which caused furtherwear of the maxillary incisors (E). Orthodontic treatment was necessary to retract the mandibular incisors (F) and to facilitate preparation (G) and provi-sionalization of the maxillary incisors (H,I ). The final restorations were placed after removal of the orthodontic appliances (J). Pretreatment (K) and post-treatment (L) photographs show the improvement in the appearance of the patient’s smile. Patient photographs reproduced with permission of the patient.

A

D

B

E

C

F

G H I

J K L

Usually the decision[between orthodontics andrestorative dentistry] willdepend on whether themaxillary incisors will

require restoration.

will depend on whether the maxillaryincisors will require restoration.

Maxillary incisor inclinationOnce we have established the correct

incisal edge position and midline rela-tionship of the maxillary incisors, thenext step is to evaluate the labiolingualinclination of the maxillary anteriorteeth. Are they acceptable, proclined orretroclined? When orthodontists eval-uate labiolingual inclination, they rely oncephalometric radiographs to determinetooth inclination.19 However, general

dentists do not use these radiographs.Another method of assessing the incli-nation of the maxillary anterior teeth isto evaluate the labial surface of theexisting maxillary central incisors rela-tive to the patient’s maxillary posteriorocclusal plane. Generally, the labialsurface of the maxillary central incisorsshould be perpendicular to the occlusalplane. This relationship permits maxi-mum direct light reflection from thelabial surface of the maxillary centralincisors, which enhances their estheticappearance.20 If teeth are retroclined or


Figure 4 This woman had short maxillary incisors (A) and significant lingual erosion of these teeth (B) due to bulimia. The amount of incisal edge visibleat rest was about 2 to 3 millimeters (C). Since the maxillary incisal edge was positioned appropriately relative to the posterior occlusal plane and her upperlip, tooth length was increased with osseous surgery. A surgical guide with proper tooth proportion (D) allowed the periodontist to establish the desiredbone (E) and gingival levels (F,G). By increasing the crown length, adequate ferrule was available (H) to create esthetically proportional anterior restora-tions (I). In spite of significant crown lengthening, the tissue health after restoration was satisfactory, and the gingival margins were located properly (J,K),which enhanced the patient’s smile.

A

D

B

E

C

F

G H I

J K L

If teeth are retroclined or proclined, correction

may require either orthodontics or extensiverestorative dentistry and,possibly, endodontics…

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proclined, correction may require eitherorthodontics or extensive restorative den-tistry and, possibly, endodontics to estab-lish a more ideal labiolingual inclination.18

The next step is to evaluate the max-illary posterior occlusal plane relativeto the ideal location of the maxillaryincisal edge. The maxillary incisal edgewill be either level with the posteriorocclusal plane (Figures 4 and 5), coronalto the posterior occlusal plane (Figure 1)or apical to the posterior occlusal plane(Figures 2 and 3). Correcting the pos-terior occlusal plane position will requireorthognathic surgery,21,22 restorativedentistry or both.18 The amount of toothabrasion, the patient’s vertical facialproportions and the position of thealveolar bone will help determine thecorrect solution of posterior occlusalplane discrepancies.

After the position of the maxillarycentral incisal edges have been deter-mined, the incisal edges of the maxil-lary lateral incisors and canines, as wellas of the buccal cusps of the maxillarypremolars and molars, can be estab-lished (Figure 2). The levels of theseteeth generally are determined by theiresthetic relationship to the lower lipwhen the patient smiles.23,24 If thepatient has an asymmetric lower lip,then it may be more prudent to use the

interpupillary line as a guide in estab-lishing the posterior occlusal plane.25

Determining gingival levelsThe next step in the process of deter-

mining the esthetic relationship of themaxillary anterior teeth is to establishthe gingival levels. The gingival levelsshould be assessed relative to the pro-jected incisal edge position. The key todetermining the correct gingival levels isto determine the desired tooth size rela-tive to the projected incisal edge posi-tion (Figures 2, 4 and 5). It is importantto remember that the incisal edge is notpositioned to create the correct toothsize relative to the gingival margin levels.Using the gingiva as a reference to posi-tion the incisal edges is risky, becausegingiva can move with eruption or reces-sion. Therefore, the ideal gingival levelsare determined by establishing the correctwidth-to-length ratio of the maxillaryanterior teeth,26-28 by determining thedesired amount of gingival display15

and by establishing symmetry betweenright and left sides of the maxillarydental arch.18

If the existing gingival levels willproduce a tooth that is too short rela-tive to the projected incisal edge posi-tion, then the gingival margins must bemoved apically. This adjustment can be


Figure 5 This woman had a cant of the gingival margins of the maxillary anterior teeth (A) owing to a right protrusive bruxing habit that had abradedand shortened the maxillary right central and lateral incisors and canine (B). The incisal edges of the maxillary anterior teeth were positioned properlyrelative to the upper lip and posterior occlusal plane (B). The maxillary right anterior teeth were intruded orthodontically (C) to level the gingival marginsrelative to the contralateral teeth. These teeth were provisionalized with composite (D) to stabilize them and complete the orthodontic treatment (E).Intrusion of the right anterior teeth facilitated the esthetic and functional restoration of the dentition (F).

A

D

B

E

C

F

The key to determining the correct gingival

levels is to determine the desired tooth size

relative to the projectedincisal edge position.


accomplished by means of either gin-gival or osseous surgery,29,30 orthodonticintrusion,11 or orthodontic intrusionand restoration.31-33 The key factorsthat determine the most appropriatemethod of correction include the sulcusdepth, the location of the cementoenameljunction relative to the bone level, theamount of existing tooth structure, theroot-to-crown ratio and the shape of theroot.34 In some situations, it is moreappropriate to lengthen the crowns of themaxillary incisors surgically (Figures 2and 4) to establish the correct gingivallevels.10 In other situations, orthodonticintrusion (Figure 5) and restoration ofthe incisal edge is more appropriate.34

The next step in the process of estab-lishing the correct esthetic position ofthe maxillary anterior teeth is to assessthe papilla levels relative to the overallcrown length of the maxillary centralincisors. Research has shown that theaverage ratio is about 50 percent contactand 50 percent papilla.35 If the contactis significantly shorter than the papilla(Figures 2 and 4), it usually indicatesmoderate-to-significant incisor abrasion,which tends to shorten the crowns and,therefore, shortens the contact betweenthe central incisors.30 If the contact issignificantly longer than the papilla, itcould suggest that the gingival contouror scallop over the central incisors isflat, which could be caused by alteredpassive or altered active eruption of theteeth.36 Either gingival or osseous sur-gery10 or orthodontic intrusion13 orextrusion34 may be necessary to correctthe level of the papillae between themaxillary anterior teeth.

Arrangement, contour and shade

The clinician now has established theincisal edge position, the midline, theaxial inclination, the gingival marginsand the papillary levels of the maxillaryanterior teeth. The next step is to deter-mine if the arrangement of the maxil-lary anterior teeth can be accomplishedrestoratively—and if not, whether thepatient will require orthodontics tofacilitate restoration. If in doubt, theclinician should perform a diagnosticwax-up (Figure 2) to confirm whether

the arrangement is possible restora-tively.18,34,37 In addition, the contourand shade of the anterior teeth must beaddressed. Does the patient have anyspecific requests concerning tooth shapeor tooth shade? Remember, the morealterations one makes in these param-eters, the more teeth one will be treatingand the more involved the treatment planwill become. A good guide to esthetictreatment planning is to determine theideal endpoint of treatment, then com-pare it with the patient’s current condi-tion. Treatment is indicated when thedesired endpoint and the current con-dition do not match. The actual methodof treatment then can be chosen on thebasis of the magnitude of the difference.

Developing the esthetic planfor the mandibular teeth

Now that the esthetic relationship ofthe maxillary incisors has been estab-lished, the mandibular incisors mustrelate to the maxillary tooth position.First, evaluate the level of the mandibu-lar incisal edges relative to the face. Dothey have acceptable display or excessivedisplay, or are they not visible at all? Ifthey have excessive display, equilibra-tion, restoration or orthodontic intru-sion are possible methods of correctingthe problem.34 If they are not visible,either restoration or orthodontic extru-sion may be necessary.38,39 Next, deter-mine the relationship of the mandibularincisors relative to the posterior occlusalplane. Are the incisors level with theposterior occlusal plane? If not, thenthey are either coronal or apical to theposterior occlusal plane. Correcting eitherof these relationships could requirerestoration (Figure 1), equilibration ororthodontics.4 Finally, the labiolingualinclination of the mandibular incisorsmust be evaluated. This relationship isdetermined partially by the projectedposition of the maxillary incisors. Ifthe inclination is either proclined(Figure 3) or retroclined, orthodonticscould be a useful adjunct in adjustingthe labiolingual position of the man-dibular incisors.34 The final mandibu-lar incisal edge position usually isdetermined during the functional and

Remember, the more alterations one makes

[to tooth shape or toothshade], the more teeth one will be treating

and the more involved the treatment plan

will become.

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structural phases of the treatment plan-ning (Figures 2-5).

The gingival levels of the mandibu-lar dentition may need to change whenthe different options for leveling themandibular occlusal plane are consid-ered. If orthodontics is selected to eitherintrude or extrude teeth, the gingivalmargins will move with the teeth.40

However, if equilibration, restorationor both are necessary to level the man-dibular occlusal plane, then the gingi-val levels may need to be relocated withosseous surgery.10

At this point, based on the estheticdetermination of the projected positionsof the maxillary and mandibular teeth,the clinician should be able to determinewhich teeth will need restoration41—that is, the maxillary anterior, maxillaryposterior, mandibular anterior and/ormandibular posterior teeth. Then, oncethe maxillary and mandibular occlusalplanes have been established throughesthetic parameters, the clinician mustdetermine how to create an acceptableocclusal relationship between the arches.

Steps to IntegratingFunction and Esthetics

The first step to integrating the esthet-ic plan with the functioning occlusionis to evaluate the temporomandibularjoints and muscles.42 Does the patienthave any joint or muscle symptoms? Akey step in the process of diagnosingthe cause of such symptoms is to makecentric relation records and mount themodels. Our definition of centric rela-tion is the position of the condyles whenthe lateral pterygoid muscles are relaxedand the elevator muscles contact with thedisk properly aligned.42 The questionthat the clinician must ask is whetherthe desired esthetic changes can be madewithout altering the occlusion. If not,orthodontics, orthognathic surgery orboth may be required to correct toothposition to facilitate the esthetic posi-tioning of the teeth. To determine theimpact of the esthetic plan on the func-tion or occlusion, the esthetic changesin maxillary tooth position must betransferred to the maxillary dental cast.42

This is accomplished with a combination

of wax and adjustment of the plastercasts (Figure 2).

As the proposed esthetic treatmentplan is transferred to the mounted casts,the clinician will be able to determineif only restoration will accomplish thedesired occlusion, or if alteration of theocclusal scheme through orthodontics,orthognathic surgery or both will benecessary. This is especially true whenthe clinician is planning to level theocclusal planes. A key question to askis whether leveling of the occlusal planescreates an acceptable anterior dentalrelationship. If the answer is yes and theleveling would involve only the mandibu-lar incisors, then the patient’s existingvertical dimension can be maintained.If, however, the answer is no or theleveling would involve mandibular pos-terior teeth, the existing vertical dimen-sion may need to be altered. The clinicianmust determine whether altering thevertical dimension will result in accept-able tooth form and anterior relation-ships. There is no replacement formounted dental casts and a diagnosticwax-up when these critical questionsare being addressed.

Determining if AdequateStructure Exists for Tooth Restoration

Once the esthetic treatment plan hasbeen established, the projected toothposition has been verified on the diag-nostic wax-up and the functional rela-tionships of the mounted dental castshave been assessed, the clinician mustdetermine if adequate tooth structureexists to allow for restoration of the teeth.If not, how will the clinician attain ade-quate structure? What types of restor-ations will be placed? How will they beretained? How will any missing teethbe replaced? Depending on the clini-cian’s assessment of the remaining toothstructure,41 the choices for restoringanterior teeth could include compositebonding, porcelain veneers, bonded all-ceramic crowns, luted all-ceramic crownsor metal ceramic crowns. The posteriorrestorations could include direct restora-tions, inlays, onlays or crowns. If teeth aremissing, they will be replaced with either


Once the esthetic treatment plan has been established…the clinician must

determine if adequate tooth structure exists

to allow for restoration of the teeth.

implants, fixed partial dentures or remov-able partial dentures. The criteria to eval-uate to determine which restorations areappropriate include

• the clinical crown length; • the crown length after any

gingival changes are performedfor esthetic reasons;

• the amount of ferrule40;• whether there is sufficient space

for a buildup;• how any crown lengthening

needed for structural purposes willaffect the esthetics (Figures 2-5).

The methods for increasing the reten-tion of restorations are buildup, surgicalcrown lengthening,10 orthodontic forcederuption33,40 and bonding of the restora-tion. Each clinical situation must beevaluated carefully to determine theappropriate structural solution.

Biology: Last butCertainly Not Least

The esthetic plan has been established.The diagnostic wax-up confirms that theteeth will function properly. The restora-tive plan has taken into considerationthe existing tooth structure. Now is thetime to add the biological aspects ofthe treatment plan.

The biological aspects include anyneed for endodontic care, periodonticcare or orthognathic surgery. The primaryobjective of biological treatment plan-ning is to establish a healthy oral envi-ronment with the tissue in the desiredlocation. To accomplish this objective, theclinician may need to perform endodon-tic procedures on teeth that are salvage-able structurally and periodontally. Inthese cases, the endodontic therapy mustbe completed first, before the restorativephase of dentistry begins. The definitiveperiodontal therapy must be establishedto create a healthy periodontium basedon the esthetic, functional and structuralneeds of the restorations. Any electiveperiodontics must be completed next,in conjunction with the restorativeplan. Finally, if there are any skeletalabnormalities that require orthognathicsurgical correction, these must be accom-plished before the definitive restorativephase of treatment.

Sequencing the TherapyThe plan is complete. It began with

esthetics, it was correlated to function,it took into consideration the remainingtooth structure, and it was facilitatedby recognition of the biological needsof the patient. The only two questionsthat remain are

• how to sequence this estheticallybased treatment plan;

• whether the patient can affordthe treatment.

The sequence of any treatment planalways should begin with the manage-ment or alleviation of acute problems.Then the remaining treatment plan canbe sequenced in a manner that seems themost logical and facilitates the next orfollowing phase of treatment, providedthe result can be identified clearly, com-municated and achieved for the pertinentphase. When we establish the sequenceof treatment for an interdisciplinarypatient, we list the steps in the treatmentplan based on our collective opinionbefore treatment begins.34,37 Everymember of the team receives a copy ofthe written treatment sequence. Thisstep ensures that each member of theteam will be able to follow the steps inthe esthetic, functional, structural andbiological rehabilitation of our mutualdental patient.

Patient typeThe economics of the interdiscipli-

nary esthetic treatment plan obviouslyis of primary importance. In a previousarticle,43 the types of patients in themodern dental practice have been divid-ed into four types (I, II, III and IV).Patients of types I and II generally donot require significant esthetic restora-tion. However, those of types III and IVtypically will require the type of esthet-ic evaluation that we have outlined inthis article.

The type III patient is a healthy adultwith no occlusal disease and no peri-odontal problems but a desire for anesthetic change (Figure 1). The type IIIpatient could be described as the esthet-ic patient, one who is dentally healthybut wishes to make a change in appear-ance. The hallmark of treating the true


The primary objective of biological treatment

planning is to establish ahealthy oral environment

with the tissue in thedesired location.

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esthetic patient is the requirement oftime on the part of the dentist.

The most challenging situation isthe type IV patient (Figures 2-5), whomwe have described in this article. Thisis an adult whose dentition is failingand who may have occlusal disease,periodontal disease, multiple restora-tive needs and missing teeth. The typeIV patient is the complex reconstruc-tion patient in any dental practice. Thehallmark of this patient is multipleappointments over months or even years,depending on his or her orthodontic,periodontal, endodontic, surgical andrestorative needs. Owing to the increasednumber of appointments and laborato-ry fees, the clinician must adjust the feesto reflect the amount of time commit-ment. For ideas on establishing appro-priate fees in these types of patients, thereader is referred to a previous article.43

SummaryEsthetics has become a respectable

concept in dentistry. In the past, theimportance of esthetics was discount-ed in favor of concepts such as func-tion, structure and biology. But in factif a treatment plan does not begin witha clear view of its esthetic impact onthe patient, then the outcome could bedisastrous. In today’s interdisciplinarydental world, treatment planning mustbegin with well-defined esthetic objec-tives. By beginning with esthetics andthen taking into consideration the impactof the planned treatment on function,structure and biology, the clinician willbe able to use the various disciplines indentistry to deliver the highest level ofdental care to each patient. We call thisprocess “interdisciplinary esthetic den-tistry,” and it really works.

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1. Historically, the treatment planning processassessed the following in which order?a. function, biology, esthetics, structuralb. biology, structural, function, estheticsc. structural, function, biology, estheticsd. esthetics, biology, function, structural

2. When assessing the position of the maxillarycentral incisor, an acceptable amount ofincisal edge display at rest depends on:a. how high the patient’s lip line is.b. the patient’s periodontal status.c. the patient’s age.d. whether the patient can occlude completely.

3. Studies have shown that midline deviationsof up to what amount are not noticed by laypeople if the long axes of the teeth are parallelwith the long axis of the face?a. 1 or 2 mmb. 2 or 3 mmc. 3 or 4 mmd. 4 or 5 mm

4. Generally, what surface of the maxillarycentral incisors should be perpendicular tothe occlusal plane?a. occlusalb. lingualc. labiald. facial

5. What characteristics will help determine the correct solution of posterior occlusal plane discrepancies?a. the amount of tooth abrasionb. the patient’s vertical facial proportionsc. the position of the alveolar boned. all of the above

6. It may be more prudent to use the inter-pupillary line as a guide in establishingthe posterior occlusal plane if the patienthas what?a. an asymmetric lower lipb. an asymmetric upper lipc. a symmetric lower lipd. a symmetric upper lip

7. When assessing the papilla levels relative tothe overall crown length of the maxillarycentral incisors, research has shown that theaverage ratio is about:a. 30 percent contact and 70 percent papilla.b. 40 percent contact and 60 percent papilla.c. 50 percent contact and 50 percent papilla.d. 60 percent contact and 40 percent papilla.

8. If the level of the mandibular incisal edgesrelative to the face have excessive display,which of the following options are possiblemethods of correcting the problem?a. equilibrationb. restorationc. orthodontic intrusiond. all of the above

9. The first step to integrating the esthetic plan with the functioning occlusion is to evaluate what?a. the density of the bone structureb. the temporomandibular joints and musclesc. the alignment of the jawd. the periodontal status of the patient

10. If leveling of the occlusal planes creates anacceptable anterior dental relationship, thepatient’s existing vertical dimension can bemaintained by leveling only the:a. mandibular incisors.b. maxillary incisors.c. mandibular bicuspids.d. maxillary bicuspids.

Continuing Education QuizLoma Linda University School of Dentistry provides 1 hour of Continuing Education credit for this article for those who wishto document their continuing education efforts. To participate in this CE lesson, please log on to www.AEID.AEGISCE.net,where you may further review this lesson and test online for a fee of $14.00. To obtain mailing instructions or for moreinformation, please call 877-4-AEGIS-1.


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