The evaluation of “the smiling area“, is difficult.
Requires to collect a series of observations (clinical exam) needed to solve a complex social-psychological-cultural problem: the aesthetic demand.
The first thing to do is to understand patient’s major complain.
He usually perceives only the bad color and misalignment of his teeth.
“My smile is ugly.”
“I can’t even laugh”
“I hate being photographed.”
“My self-esteem does not exist, I’m depressed.”
Maybe I need counselling. But psychologist doesn’t have a clue about teeth.
The demand is very clear. The diagnosis no.
It’s not about the money!
Diagnosis and Therapy, although parts of the same process, are two different procedures, with different purposes.
The diagnosis is the duty of every physician. Understanding the history, nature and implications of a disease of a patient, requires time and commitment.
The aesthetic problem involves the perception of oneself. It needs also to get a deepen knowledge of patient’s psyche.
You have to listen. You have to observe and analyze the posture, attitude, facial pattern, way of expression. Listen to the soul of a person. Understand his/her fears and insecurities. Draw a personality profile.
An aggressive, narcissist, self-centered profile, shape of teeth will be edgy, nearly triangular. The color should be bright white, whiter than white. The value (brightness) high. The size appropriate.
In a middle-aged woman, latin, solar, an oval shape fits very well in a context of full lips, sensual.
At the same time, analysis of objective data occurs: clinical examination, x-rays, impressions for plaster models, photographs, videos.
Treatment planning, however, is a complex procedure, where experience, intuition and common sense of the doctors meets.
The treatment plan is the result of a complex brain-process. The huge amount of data and information acquired will be analysed and integrated with the personal experience of the profi… if you have one in front of you! Otherwise your only choice is to try fortune. A real disaster. Treatment plans never end.
To draw priorities and operative work-flow, foresee second solution in the event of complications, pre-visualize end-result, it’s kind of art. Can not be calculated. It’s a matter of Intuition.
Teeth are the center of the smiling-system.
Changing color of teeth, if possible, lights up someone’s soul. The teeth whitening procedures – the Americans “bleaching” – whereas possible (we will discuss it in a separate article), improves the chroma (color) and value (brightness) of the teeth. The smile becomes brighter.
But it’s supposed to be a guy with no other problems … like him!
In most cases, may be a too simple instance.
The not appropriate contour of the face, the lack of proportion between the different underlying skeletal segments (forehead, eyes, nose, upper jaw, lower jaw, chin), marked asymmetry between the two halves, are factors that affect the soft tissues.
Lip animation during smile.
Lips are the “natural frame” in which teeth are inserted. The main value of social interaction.
Beautiful lips surrounding beautiful teeth, greatly enhance them.
Here’s the point of cosmetic treatments of the lips: fillers. And women, plastic surgery addicted, are all alike: it’s the American Way! Lips and teeth are standard. Offending the uniqueness of the individual. The magic of a smile.
On the contrary, a well balanced face, with harmonic features, can be “devastated” by ugly teeth of bad shape, misaligned, with malocclusion… and a “frustrating” color!
The aesthetic evaluation has to start from a dynamic analysis of the facial animation.
The dynarnic display zone is quite literally a moving target.
There exists a “posed” smile, forced, for convenience or courtesy. The “social” smile. The mimetic muscles of the face are only partly recruited from the will. With a bit of training, actors and politicians – who are mostly alike – they can almost seem to be spontaneous.
But there is also a spontaneous smile, the enjoyment smile, totally involuntary. In this case, all the muscles of the face are involved. Not only the orbicularis muscle of the lip. The orbicularis oculi muscle too. Laughing with our eyes, as well as with our lips, is an expression of a true emotion of the soul. Being recruited all facial muscle at the same time, the patient will discover more teeth.
Our point is to evaluate the aesthetics of the smile in the range of dental exposure, between the rest position, when the patient speaks normally (phoneme “m”), and that of maximum muscle recruitment, when he smiles spontaneously.
That is to say?
How much is the portion of the tooth (clinical crown) that patient display through the lips, in different situations.
Otherwise when patient’s got his final restorations, comments will be:
“Beautiful teeth, but when I talk they disappear!”
“I got wrinkles around the lips, I look older!”
“You put me on big teeth, I’m looking like a shark.”
The check “list” of things to pay attention to:
The proportions of the face (front view)
- an ideal face is evenly divided into upper 1/3 (front), medium 1/3 (eyes, nose and base of the upper lip), lower 1/3 (upper teeth-lower-chin),
- presence of asymmetry
- distance between eyes
- size of the nose: may be prominent only because in disharmony with the upper jaw and chin, or has a big hump, or the tip is large, or is simply too big (Rhinoplasty is needed)
The skeletal pattern (lateral view)
I. skeletal class: the skeletal profile is balanced with the rest of the face
II. skeletal class:
- the jaw is too small or back-positioned (the nose is prominent, upper teeth are bend towards the palate);
- the upper jaw is too prominent, lower jaw in normal;
- or the defect concerns both jaws
III. skeletal class:
- lower jaw is too big, the teeth generally try to compensate for the defect: upper forward and lower inward;
- or the upper jaw is too small, the lower jaw is normal
- the defect concerns both
The lips: the display zone
- if they are thick or thin
- the length. The measure of “filter”, that little bit of lip that lies underneath the tip of the nose, gives us a clue of what the lip is responsible for the amount of dental exposure
- color: beautiful color means a beautiful framing of the teeth
- check whether they are natural or “fixed” by the fillers, botox, etc..
- age: aging upper lip lengthens and prevents the correct exposure of the upper teeth; in addition, the lower lip loses tone and you see a lot more lower incisors!
The gum
- amount of gum exposed (typically 2-3 mm) during smiling
- quality of gum (if they are sick they will be red-violet and swollen; periodontal care radically change appearance!)
- the scalloping: the gingival frame has great effect on teeth shape
The teeth
- vertical display of the incisors (length)
- inclination of the incisors in the lateral view (sagittal plane)
- harmony of the occlusal plane: when the upper back teeth “fall down” on one side or both, there is something wrong!
- lateral spaces between cheek and teeth (the dark side corridors)
- vertical dimension of teeth: for example, when the lower incisors disappear behind the upper incisors (deep bite), or when the teeth are worn out becaouse of grinding or clentching over the years, (sometimes due to the same treatment of the dentist, performed badly, on the posterior teeth – fillings or crowns occlusally undersized!)
- relationship between upper and lower front-teeth:
overjet: distance between the upper and lower teeth (1-2 mm)
overbite: vertical overlap (1-2 mm)
openbite: open bite
- Relationship between teeth and skeletal bone bases: as above mentioned- the skeletal class
- Angle class: mutual position of teeth in both arches
- misalignments: dental crowding.
Shape and Volume of one incisor
- a worn tooth, will be shorter than normal
- badly restored incisors, change shape and volume
- an “old” tooth will have lost the enamel and whitening procedure … will be useless missing the target of bleaching!
The microscopic surface of a tooth (texture)
- incisor of a 20-year boy/girl has enamel thick and porous, it refracts light very well
- the same tooth at 50 years, will be “planed” because of ravages of time and the dentist’s mistreatment, not realizing that the more you polish it, the more brightness lowers.
The color
The color of a tooth is made up of Hue, Chroma and Value. It ‘a very complex technical matter. Requires a separate article. To realize a beautiful color, that fit’s in, is kind of sophisticated art. Requires a very skilled technician…and good taste!
The dynamic display zone (facial expression) is the mirror of our emotions.
Teeth, represent the starting point and arrival, at the same time.
This article is an attempt to simplify a very complex subject, where many disciplines are overlapping: general dentistry, orthodontics, maxillofacial surgery, plastic surgery, prosthodontics, dental technician’s skill and … psychology.
The Patient naively asks the numbers: costs, success rates, timing and methods.
He thinks – but it is not his fault, that’s in newspapers, on TV and internet – it’s only a matter of protocols. The dentist follows it, result is a matter of course.
My personal opinion? It’s not that easy…
dr. Massimo Mazza
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