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Beautiful Smiles by Design

By Dr. Stephen R. Snow

This article is endorsed by the
American Academy of Cosmetic Dentistry.


“You Are Here”

Photo showing example before smile design treatment. Photo showing example after smile design treatment.
Figure 1: Before treatment, a cosmetic dentist looks at the overall composition of a patient's face in determining the final smile design. Figure 2: By intentionally selecting materials, dimensions, and proportions that balance with the patient's face, the dentist can create a final result that is attractive and balanced.
Photos provided by Dr. Stephen R. Snow

You've seen it on posted diagrams on the walls of large buildings: “you are here.” It is only after you know where you currently are that you can effectively navigate your way and decide which way to turn. The same is true of cosmetic dentistry which is both an art and a science. The dentist must fully evaluate all aspects of the patient's oral status to determine the starting point. A comprehensive examination is the key.

Understandably, many patients tend to focus exclusively on their esthetic concerns. As a part of the comprehensive evaluation, the dentist performs a smile analysis. Researchers and artists have carefully studied beautiful smiles and have discovered several recurring themes that combine to create attractive smiles. Among these are facial balance — the elements of the smile that relate to each other, blending within the context of the entire face [Figure 1 and 2]. Facial shape is important, for example some may have an overall oval form, and others are more square or even tapered in outline. In addition to facial shape and type, many other characteristics are important: asymmetries, skin color and complexion, eye color and position, lip form and posture, and smile dimensions. Believe it or not, taking into account the overall look of the face will have a substantial bearing on the eventual appearance of the teeth and gums. The cosmetic dentist observes all of these factors and considers how the shape and position of the teeth themselves enhance or detract from the mix of facial features.

Figure 3. Figure 4.
Figure 3: The proportion of the teeth and gums displayed in a full smile are key factors in evaluating the esthetic zone. Figure 4: Cosmetic dentists often utilize lip retractors to create photographs for smile design purposes. When teeth are well-aligned, evenly colored, and proportionally shaped, the resulting smile is often pleasing.
Figure 5. Figure 6.
Figure 5: When an excessive amount of gums are revealed in a smile, the teeth may look proportionally small and insufficient. Figure 6: Misalignment, asymmetry, decay at the gum line, and chipped edges all combine in forming a smile that is less than ideal.
Photos provided by Dr. Stephen R. Snow

When the lips part during a smile, it is like a theater curtain going up to reveal the stage behind. In addition to the shape and posture of the lips, other smile analysis themes include the esthetic zone principles in which the dentist looks for a blend of the proportions of teeth, gums and shadows as they are revealed in a full smile [Figure 3-6]. Gum esthetics are determined by the frame and color that the gums create around the teeth; tooth esthetics are determined by relative proportions of shape and size, alignment, symmetry and the arrangement of teeth in the upper and lower jaws and even how they relate to each other. Finally, themes in the tooth characterization category are used to evaluate the color and contour qualities. Together, these principles combine to create the visual impact of your smile. With a perceptive visual evaluation and the aid of high quality specialized dental photography, the dentist and the patient can evaluate which of these specific factors contribute to a person's disapproval with their smile.

Beyond pure cosmetic concerns, however, the highest priority for any medical professional is to care for the health of their patients. As noted before, esthetic problems (missing, misaligned or discolored teeth) are often an indication of underlying dental disease or an inherited problem. A full periodontal evaluation is important, that is a determination of whether the supporting structures of the teeth, the bone and gum tissues are healthy since these are the foundations upon which the teeth are supported. Even though a patient may not be aware of the presence of some of these problems, the dentist's first obligation is to make sure they are healthy.

The remainder of the comprehensive examination, then, incorporates the evaluation categories that comprise a complete oral health analysis. Through the use of radiographs, photographs, models, measurements, and direct clinical observation, the dentist analyzes the function of the patient's jaw joints, the stability of the bite relationships, and the health of the teeth and gums. After accumulating this full set of data, the dentist will use all of these findings in combination with the smile analysis to make a “definitive diagnosis” — the dental equivalent of “you are here.” With a firm grasp on this starting point and a clear focus on the desired destination, the patient and doctor are now ready to consider the options in charting a course of action.

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