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Kirtley

Restorative Dentistry

The Art of a Beautiful Smile

byGeorge E. Kirtley, DDS, Introduction


In much the same way an artist uses brushes and paint to create his or her
AAACD, ABCD
Indianapolis, IN art, we too must approach what we do, using the face and its features along
www.smilesbygeorge.com with our instruments (e.g., handpiece, laser, imaging systems) to do the same.
However, to approach esthetic dentistry successfully, one must understand the
distinction between “craft” and “art.” Craft is the mechanics (the step-by-step
protocols and procedural methodology that we have learned through years of
experience) of what we do, and art is the quality of what we do. The ability to
create art must first include a thorough understanding of the craft. The art or
quality of what we do cannot be reduced to a mere formula or procedure. It is
the intangible that is acquired only through observing and doing. One must
observe the masters, just as an aspiring artist must watch and learn from the
masters of his craft. It is the skill acquired with the development of a discern-
ing eye that differentiates the mechanic from the artist. When the discerning
and learned eye is combined with a foundation of mechanics, the functionally
beautiful smile is created. As with all constructive endeavors, predicting a suc-
cessful end result is impossible without a blueprint to follow. It would be the
same for the portrait artist whose desire is to accurately depict the beauty of his
model by creating accurate proportions, yet has no references to accomplish
that. And, it is like the esthetic/restorative dentist who expects incomparable
esthetics and function by picking up the handpiece and starts to cut without
any perspective or defined vision of the end result.

As with all constructive endeavors, predicting a successful end result is


impossible without a blueprint to follow.

The two main objectives in dental esthetics are 1) to create teeth of pleas-
ing inherent proportion and proportion to each other; 2) to create a pleasing

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Kirtley
Restorative Dentistry

Figure 1B: Note disharmony between incisal edges and


commissural reference line.

Figure 1A: Frames and subframes


within the context of the face. tooth arrangement in harmony with Horizontal Lines of Reference
the patient’s lips, gingiva, and face.1 The most commonly used hori-
The esthetic/restorative dentist must zontal reference line is the bipupil-
clearly realize the inter-relationship lary line1 (the line drawn between
between these components to effec- the pupils of the eyes). This line’s
tively create an esthetically function- lack of parallelism to the gingival
al smile. As the portrait artist works margins of the central incisors and
within certain frames and references incisal/occlusal plane often signals
to create a visually pleasing result, need of correction to attain visual
the esthetic restorative dentist, too, harmony in the smile. Other hori-
must utilize these frames of refer- zontal lines of reference would be
ence to establish the smile’s propor- the ophriac (eyebrow), intra-alar,
tion, symmetry, and balance. Use of and commissural (corners of the
these references are an integral part mouth) lines (Fig 2).
in the accurate design of facial es-
thetic reconstruction, of which the Vertical Lines of Reference
smile is of paramount importance The midfacial or skeletal mid-
(Figs 1A & 1B). line enables the visual orientation
of the midline of the face relative to
Extraoral Features Affecting the midline of the dentition.1 This
Smile Design highlights the coincidence (or lack
thereof) between the two, giving the
These references include—but are
Figure 2: Horizontal and vertical clinician a perspective on medio-lat-
reference lines on the face. From top: not limited to—horizontal and ver-
eral discrepancies of the dental mid-
Ophriac line, bipupillary line, alar tical lines drawn between anatomi-
line location, left-to-right symmetry,
line, commissural line. cal landmarks of the face. A com-
and what changes from a vertical
parative analysis serves to provide us
standpoint would be necessary to at-
with information as to the harmony
tain optimum esthetic results of the
or visual tension that exists between
smile. Additionally, it can provide
them and the dentition we strive to
reconstruct and enhance.

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Restorative Dentistry
Kirtley

Figure 3: Preoperative images showing excessive gingival display and buccal corridor deficiency
(1:2 frontal and full-face views).

Figure 4: Postoperative images (frontal and full-face views) showing correction of esthetic deficiencies.

Figure 5: Preoperative view showing deficient incisal edge length, and postoperative view showing
elongation of incisal edges following the curvature of the lower lip line.

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Kirtley
Restorative Dentistry

Figure 6: Incisal edge position (determined by phonetics, Figure 7: Parallelism of incisal edge and
function, and esthetics). gingival margin.

Figure 8: Esthetic gingival architectural design from central incisor to cuspid to premolars.

a visual cue as to the degree of the The incisal edge of the maxillary cantly to the smile’s overall artistic
teeth’s axial inclination (Fig 2). central incisors is the single most value. Most important are the gin-
important determinant in function- gival tissues surrounding the denti-
Lip Lines ally esthetic smile design, and it is tion.
Position of the upper lip can af- the lower lip line that contributes to Gingival architecture differs from
fect the amount of tooth displayed its positional design. The curvature one patient to the next. What is con-
during the act of smiling and at rest. of the lower lip also serves as a refer- sistent in the esthetic gingival pat-
Additionally, the movement of the ence to the incisal plane/smile line terns is the location of the gingival
upper lip determines the extent of (Figs 5 & 6).1 margins being parallel to the bipu-
exposure of the teeth and gingival
pillary line, with the lateral incisor
margins during smiling. This is of
particular help to the clinician in
Intraoral Features Affecting zenith being at or below the line

evaluating the need for esthetic gin-


Smile Design drawn between the central incisor
and the canine (Figs 7-9).2 When
gival contouring or crown lengthen- Gingival Architecture gingival asymmetry or imbalance
ing in the anterior region and in the
As much as extraoral references occurs, balance must be created
buccal corridor area (Figs 3 & 4).
are important in designing a smile, through either simple (laser con-
intraoral features contribute signifi-

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Restorative Dentistry
Kirtley

Figure 9: Parallel relationship of gingival margins of


central incisors, incisors, incisal edge, and bipupillary line.

Figure 10: Axial inclinations of teeth from the frontal view.

touring) or more involved surgical cated just distal to the vertical mid- shortens as you move posteriorly,
means. line of the tooth. The laterals exhibit with the longest contact between
a more distal inclination to the ver- the central incisors. The length of
Tooth Design tical midline, and the cuspids even the contact area between the central
Within the context of tooth de- more so (Fig 10). incisors ideally is 50% of the length
sign there are many points to con- of the central incisor. The contact
Incisal embrasure form: De-
sider, any of which can dramatically area between the central and lateral
pending upon the depth and angu-
affect the artistic look for which we is 40% of the length of the central
lations of the embrasure (Fig 11), in-
strive. The axial inclinations, incisal incisor, and between the lateral and
cisal embrasure form can create the
embrasure form, contact areas, tooth cuspid it is 30% of the length of the
illusion of a more mature esthetic
dimensions, characterizations, and central incisor (Fig 12).2,3
design or a more youthful one.
color are all factors that we can alter
Contact areas: The interdental Characterizations: The character-
and define, enabling us to attain the
contact areas are simply those areas istics of teeth differ with age. Young
desired esthetic result.
where the teeth touch each other teeth are brighter owing to greater
Axial inclinations: When viewed amounts of enamel; older teeth are
interproximally. The length of these
from the frontal perspective, the darker due to the loss of enamel and
contact areas in the esthetic smile
tooth axis of the central incisor is lo- the show-through of the underlying

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Kirtley
Restorative Dentistry

Figure 11: Esthetic incisal embrasure form, showing


increasing depth from centrals posteriorly.

30% 40% 50%

Figure 12: Preoperative view of contact relationship of teeth and postoperative view of proper contact relationship of teeth.

dentin. Younger teeth have more We know that the most influen- correct wear, limited tooth display,
texture, resulting in a more reflective tial factors in a harmonious anterior or unesthetic tooth/crown propor-
surface and brighter appearance. All dentition are the size, shape, and tion. The location of the incisal edge
of these characterizations can be ar- position of the maxillary central in- obviously affects the esthetic design.
tistically designed into the ceramic cisors. They are the most important The length and width ratios of the
restoration, depending upon the ef- factor in the design of a functionally central incisors can vary because of
fect we wish to create in our smile esthetic smile. The design of the cen- this, and the formula of the “golden
design (Fig 13). tral incisors begins with the estab- proportion” may not be followed.
lishment of the proper incisal edge
position, which is determined not
Proportion The most commonly used horizontal
only by esthetics, but also by func-
The most dramatic artistic effect reference line is the bipupillary line.
tion and phonetics.4 Many of the es-
is the creation of proper proportion.
thetic concerns we see are a result of
All of the above factors pale in im-
disproportion of the central incisors
portance to proportion and its over- Golden Proportion
to each other and to the surround-
all effect on the smile. Golden proportion is a term often
ing dentition. Often there is the
need to elongate the incisal edge to heard in relation to dental esthet-

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Restorative Dentistry
Kirtley

cervical shading
line angles

surface texture

translucency
incisal halo

Figure 13: Designed surface characterizations.

Figure 14: The importance of dental and facial proportion relationship.

ics. However, its consideration in differences between male and fe- What more accurately aids us
true esthetic and artistic form can be males, with females’ canines dis- in our smile design efforts is the
over-emphasized. At most, it should playing a larger width than males’.6 concept of “recurring esthetic pro-
be considered a tool and not a rule. In his book, The Science and Art of portion,” which advocates using
The golden proportion as it relates Porcelain Laminate Veneers, Dr. Galip a proportion of your own choice,
to dentistry states that if the appar- Gurel states, as long as it remains constant as it
ent size of each tooth (as observed “If the original definition of the moves posteriorly.7 This idea indi-
from the frontal view) is 60% of the Golden Proportion is applied to vidualizes smile design based on the
size of the tooth anterior to it, the dentistry then we would assume anatomical features specific to that
relationship is considered to be ar- that all anterior teeth would display patient. Although it may differ from
tistically pleasing.2,5 Although this a relationship that is uniform and the golden proportion formula, the
may be generally true, studies have perfect for everyone…reality tells esthetic results are often superior to
shown that the majority of beauti- us that this is questionable because what we can achieve through strict
ful smiles evaluated do not coincide everyone does not possess the same adherence to predefined mathemat-
with the exact golden proportion facial morphology, lips and propor- ical ratios (Fig 14).
formula, and that there are distinct tions and dental arch design.”6

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Journal of Cosmetic Dentistry ©2008
Fall 2008 • Volume 24 • Number 3
Kirtley
Restorative Dentistry

Figure 15: Preoperative treatment view of patient


to be imaged.

Figure 16: Computer-imaged view of patient. Figure 17: Final postoperative treatment view.

Computer-Generated Imaging dentist, and laboratory technician for a case, measurements, reference
to Aid Smile Design all can view the case preoperatively points, formulas, and calculations
Anatomically correct computer- from frontal (Figs 15-17), lateral, are used, enabling that surgeon to
generated imaging is a tremendous and full-face perspectives (Envision more predictably gain the result in-
aid, not only in educating the pro- A Smile imaging software [Envision tended. Before an instrument is even
spective cosmetic patient, but also A Smile; Indianapolis, IN]). lifted, a clear path of intent has been
in enabling the doctor to evaluate established. The blueprint is in or-
der. There should be no difference
proper length, width, proportion, Conclusion
and even shade issues before treat- in the approach we take to artisti-
When a portrait is painted, the
ment is implemented within the cally create a smile. The principles of
artist first creates an oval on which
context of the patient’s extraoral artistic design are as much a part of
vertical and horizontal lines are then
features. It is equally important in esthetic dentistry as they are for the
drawn as references. These referenc-
providing a clear line of communi- portrait artist or the cosmetic sur-
es enable the artist to create symme-
cation to the laboratory technician geon. When followed with a solid
try and balance for the anatomical
as to what is esthetically desired foundation of craft (mechanics),
features that will be drawn within it.
in the ceramic design. The patient, they result in a functionally correct
When a cosmetic surgeon prepares
and highly esthetic smile.

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Journal of Cosmetic Dentistry ©2008
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Kirtley

References
1. Chiche G, Pinault A. Esthetics of Anterior
Fixed Prosthodontics. Hanover Park, IL:
Quintessence Pub.; 1994.
2. Goldstein RE. Esthetics in Dentistry (2nd ed.,
pp. 133-186). Hamilton, ON: BC Decker
Inc.; 1998.
3. Lombardi RE. The principles of visual per-
ception and their clinical application to
denture esthetics. J Prosthet Dent 29:358-
382, 1973.
4. Vig RG, Brundo GC. The kinetics of anterior
tooth display. J Prosthet Dent 39:502-504,
1978.
5. Preston JD. The golden proportion revis-
ited. J Esthet Dent 5:247-251, 1993.
6. Gurel G: The Science and Art of Porcelain
Laminate Veneers. Hanover Park, IL: Quin-
tessence Pub.; 2003.
7. Ward DH. Proportional smile design using
the recurring esthetic dental proportion.
Dent Clin North Am 45:143-154, 2001.

AACD Acknowledgment

Get More.
The American Academy of Cosmetic
Dentistry recognizes Dr. George Kirtley
as an AACD Accredited Member and
thanks him for restoring the smile of a
Give Back A Smile™ survivor.
Editor’s Note: Dr. Kirtley is the
developer of the Envision A Smile
software that is mentioned in this
article.
______________________
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