Cosmetic/Esthetic - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Improving communication through technology

The template calls for the image at 225 by 175 but adjustments can be made within reason

Dentists know that conveying the appropriate information to patients and dental team members is integral to successful treatment outcomes.

Visual depictions of oral health needs and treatment options have been shown to be best, though typically the most difficult to produce. That’s because models, drawings and other traditional methods lack the capacity to represent patients’ individual conditions specifically, thus weakening their efficacy.

The spring 2014 issue of the International Journal of Esthetic Dentistry includes a case report using a computer tablet and applications to improve communications, particularly between dentists and patients and dentists and dental laboratory technicians.

It describes steps for producing an esthetic analysis—crucial in planning an appropriate choice of surgical and prosthetic procedures—to obtaining a digital mock-up of the case and ultimately analyzing the final restoration.

“The end result is more information delivered in less time, with a consequent improvement of the clinical outcome and a simultaneous reduction of chairside time,” the report’s author concludes.


Setting guidelines on smile esthetics

The template calls for the image at 160 by 160 but adjustments can be made

What constituted an esthetic pleasing smile had long been based on authors’ opinions, rather than evidence-based literature. However, the ability to digitally manipulate images offers new opportunities to meet the high demand for objective guidelines on the perception of smile esthetics.

Authors publishing in the December 2013 issue of the Journal of Esthetic and Restorative Dentistry noted that many characteristics have been better elucidated through the use of digital technology—the smile arc, the optimal amount of gingival display and the ideal amount of buccal corridors among them.

Nevertheless, some measures used as clinical parameters have not yet been scientifically validated, the authors reported. Because the upper front teeth are the key determinant in evaluating smile esthetics, their ideal vertical position is an aspect of paramount importance. Still, unanswered questions remain, they said. Among them: What is the most attractive vertical position of the upper central incisors, with respect to gingival contour and incisal edge? What is their most pleasing vertical position when taking into account the central incisor edges relative to the laterals and the central incisor gingival margins with respect to the canines?

Seeking answers, they conducted a study to determine the perception of smile esthetics among orthodontists and laypeople with respect to different vertical positions of the upper front teeth in a frontal smile analysis. They also assessed the role of gingival margins and incisal edges in the evaluation.

Their approach centered on a frontal close-up photo of a smiling 27-year-old Caucasian female, who displayed a highly attractive smile, according to subjective principles of an ideal smile described in the literature.

The image was digitally altered to create six different central incisor vertical positions in 0.5-millimeter increments. The images were assessed in three different views: full smile, gingival close-up excluding incisal edges and incisal close-up excluding gingival margins.

The images were randomly assembled in an album that was given to 120 judges: 60 orthodontists and 60 laypeople with college educations but no dental background. Each judge evaluated the attractiveness of the images using a form with 100-mm visual analog scales printed for each image. The scale ranged from “very unattractive” to “very attractive.”

Analyzing the results, researchers concluded that the highest rated smiles showed two notable characteristics: the central-to-lateral incisal step was 1.5 mm. The central incisor gingival margins matched the laterals, and both were 0.5 mm below the line of the canine gingival margins.

Also among their conclusions was news that gingival margins have minimal impact on the overall perception of smile esthetics, whereas the incisal edge relationship plays an important role in the overall viewpoint.

In fact, ultimately, the contour of the incisal edges was determined to be the single most important variable in perception of smile esthetics.

“With this in mind, when deciding upon the ideal vertical position of the upper central incisors in a given case, the clinician should give more priority to proper positioning of the incisal edges instead of gingival asymmetries,” the authors advised in their discussion.


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Matching shades of porcelain veneers

The template calls for the image at 180 by 180 but adjustments can be made

Patients who choose to restore their front teeth with porcelain veneers expect superior esthetics. In fact, the slightest mismatch in shading may be seen as a complete failure on the part of the dentist.

Yet predicting final color isn’t without its difficulties. Dentists have interacting variables to consider, including the color of the tooth structure, the type of resin cement, and the color and translucency of the milling block.

Scientists publishing in the spring 2014 issue of the International Journal of Esthetic Dentistry noted that a previous study showed that final color was directly influenced by the color of the underlying tooth structure, while the color of the resin cement had a negligible effect.

Considering the variety of ceramic blocks for milling porcelain veneers available to optimize shade match of CAD/CAM produced porcelain veneers, the scientists aimed to investigate the influence of their color and translucency when using resin cements of two different opacities.

To conduct their research, they prepared an upper right central incisor for a porcelain veneer and then duplicated it using composite resin restorative material. Resin dies were individually laser scanned in order to build a 3D model of the porcelain veneer on CAD software.

Researchers used three types of leucite glass ceramic CAD/CAM milling blocks –—multichromatic, high translucency and low translucency—to fabricate 20 veneers from each block. Their intention was to shift the dark color of the resin dies (A4) to a lighter target color (A1).

They used high-opacity resin cement for half of the specimens in each group and low-opacity resin cement for the other half. Color parameters were measured at the incisal, middle and cervical third of each cemented restoration using a digital shade guide device, and the values of the cemented veneers were calculated against the target color.

Although researchers detected color shift from a dark shade (A4) towards a lighter (A1) from cementing the veneers on the resin dies, the type of milling block did not have an observable effect on final color. Also, the opacity of the resin cement did not have a significant effect on the final shade match.
The results showed that the three types of blocks produced similar results, even when used with two different opacities of resin cements. The variations in the translucency of CAD/CAM milling blocks did not affect color match and all produced veneers failed to mask the baseline color (A4) completely.

The opacity of resin cement was ineffective in blocking the color of underlying tooth structure as well. The final shade was almost comparable using high- and low-opacity resin cements, the authors explained.

“The final color of porcelain veneers is the product of the interaction of color of the original tooth, and the translucency and thickness of both the resin cement and the ceramic veneer,” they said.

Although different results may be expected using lithium disilicate CAD/CAM milling blocks, considering the materials used in their study, “the shade match of CAD/CAM produced porcelain veneers was not influenced by the translucency of the used milling block or the opacity of the resin cement,” the authors reported.


Microabrasion for esthetic management of fluorosis

The template calls for the image at 160 by 160 but adjustments can be made

Is enamel microabrasion a good option for treating mild-to-severe dental fluorosis?

Although the technique has been studied since 1986, its clinical performance is still debated, according to scientists publishing in the December 2013 issue of the Journal of Esthetic and Restorative Dentistry. While some authors have reported high patient satisfaction and called the treatment an efficient, safe and simple method for removing fluorosis stains, others found the results unsatisfactory without further treatments, such as vital bleaching and composite restorations.

Previous studies have suggested that because microabrasion only removes the outer enamel surface, its efficacy wanes as stains, opaque areas and porosities increase with the severity of fluorosis.

The scientists tested that supposition by conducting a study of 154 teeth divided into three groups according to their degree of fluorosis: Group 1—mild (53 teeth); Group 2—moderate (56 teeth); and Group 3—severe (45 teeth). The aim was to evaluate the effect of severity of fluorosis on the clinical performance of enamel microabrasion.

Although scientists treated all teeth with visible fluorosis stains, only upper and lower incisors and canines were included in the study. A total of 14 patients (4 male and 10 female) ranging in age from 19-to-38 years of age participated in the trial.

Photographs were taken under the same conditions both before and 24 hours after enamel microabrasion. Two examiners who did not provide the treatment compared before-and-after images by using visual analog scales (VAS) to score:

Researchers also evaluated “requirements for further treatments” for each tooth using a three-point scale.

Analyzing the findings, they learned that the “improvement in appearance” score was significantly lower for the group of teeth with severe fluorosis than for the teeth in the mild or moderate categories.

“Changes in opaque white areas” scored highest for teeth with mild fluorosis. The results for teeth with moderate and severe fluorosis did not differ with respect to “changes in brown stains,” but scored higher than they did for “changes in opaque white areas.”

“Requirements for further treatments” yielded significant differences between study groups. For example, the proportion of patients who needed further treatment was significantly higher for those with severe fluorosis (Group 3) than for patients in Groups 1 and 2. The need for further treatment also was higher in patients with moderate fluorosis (Group 2) than in patients with a mild condition (Group 1).

In discussion authors said that, considering the benefits of microabrasion, it should be the first option in the management of fluorosis stains—and not only for the aesthetic improvement of mildly fluorosed teeth.

Although the treatment may be an inefficient and redundant option for moderate and severe fluorosis, the removal of opaque white areas and brown stains with the help of microabrasion may increase the success of further treatment, the authors said.

“For instance, it may shorten the duration of subsequent vital bleaching, which may reduce the cost and adverse effects of this treatment or may provide more aesthetic results using more conservative preparation when a composite resin is required after microabrasion,” they added.

Commentary published within the journal’s same issue reflected on the evolution of the technique, from its origins in the early 1900s when Dr. Walter Kane used hydrocholoric acid in a controlled manner to dissolve superficial stain, through its years of research and eventual emergence as a routine clinical procedure in dentistry.

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The material’s physical and handling properties contribute to reduced volumetric shrinkage during polymerization for improved marginal fit. In addition, the material’s shrinkage stress reliever equally distributes forces across cavity walls and surfaces to improve the elasticity and integrity of the restoration. This characteristic also lessens the likelihood of postoperative sensitivity, micro-leakage and secondary caries, all of which are advantageous for patients, both immediately and long term.

Tetric EvoCeram Bulk Fill contains a patented geranium-based light initiator and polymerization booster (i.e., Ivocerin). This component allows dentists to place, sculpt and cure 4-millimeter-thick increments of the composite in 10 seconds using conventional LED curing lights for more efficient treatments. However, adequate working time is assured by the light initiator’s light sensitivity filter, which delays the composite’s reaction to ambient light.

This allows the material to be placed with conventional dental instruments, eliminating the need for supplementary equipment that could add time and complexity to the restorative appointment. The material’s well-balanced filler composition produces a plaque-resisting high-gloss polish that blends well for a natural appearance and esthetic look.


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Cosmetic dental courses at ADA 2014

ADA 2014, America’s Dental Meeting, will feature 14 courses on esthetic/cosmetic dental subjects, including a full-day course on “Botox Therapeutic for Every Dental Practice,” presented by Dr. David Kimmel and faculty of the American Academy of Esthetic Dentistry.

ADA 2014 is scheduled for Oct. 9-14 in San Antonio. Other presenters on cosmetic dentistry will include Drs. Lee Ann Brady, James Braun, Jeff Brucia, Gerald Kugel and Paresh Shah.

Registration for the meeting opens online May 1 at


ADA offers discount on Smile Makeover brochure

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Dentists can save 15 percent on the best-selling ADA Smile Makeover brochure using the promo code 14318E. This discount, valid through April 15, also applies to all other patient education and personalized materials offered in the ADA Catalog.

Smile Makeover (W213) will help open your patients’ eyes to the possibilities of a brighter smile. This brochure explores the effects of age on teeth and gums and examines various procedures used to revitalize teeth that are discolored, unevenly spaced or misaligned, missing or worn down.

It explains to patients various smile-enhancing dental procedures, including orthodontia, veneers, reshaping, whitening, tooth-colored fillings and bonding. The eight-panel brochure is available to members in packs of 50 for $27; retail price, $40.50.

Smile Makeover also can be personalized (DAB022) with your name or practice information—ideal for new patient welcome packets, and waiting areas of referring dentists and physicians.

To preview Smile Makeover and a wide range of other ADA cosmetic brochures, visit Discounted pricing also is available for higher quantities.

Orders can be placed online at or by calling the ADA Member Service Center at 800.947.4746.