Smile Design: Aesthetic Dentistry Planning Guide

“A smile is the shortest distance between two people.” – Unknown

When people, are unable to smile, even when they want to, simply because they are ashamed of doing so, it causes a whole host of social issues, especially with regards to relationships with people. The lack of a smile very quickly becomes the cause for increasing the distance between two individuals, often due to misunderstandings. As such the worth of a simple smile, is largely underestimated.

As dentists, we are uniquely suited to help people overcome issues with their smile professionally. But it isn’t that easy to design a smile i.e., where both we, the clinician as well as the patient are satisfied with the final outcome. To help circumvent that, I will be sharing ten tips, on how best to handle such cases, in this article.

1) Strike a balance between what YOU want and what the patient wants.

Many of us find ourselves rubbing our hands in glee, when confronted with a complex case. We start imagining the end result, replete with high end, fabulous metal free indirects, and the fantastic before and after images on our social media, while we sit grinning like a Cheshire cat at all the praises pouring in! Nothing wrong with this of course, but sometimes, our wild imagination needs to be tempered with a dose of reality. What we want may or may not be what the patient wants! As a clinician, what we want is often ideal treatment (treating everything we see wrong with the best of materials) and what the patient wants is compromised treatment (constraints of budget, time, finances etc). If we want to be successful in clinical practice, we must learn to strike a healthy balance between the two.

2) Analyse the case thoroughly.

Not every smile design case is suited for minimally invasive veneers. At the same time, treating every case with crowns may not be the right solution. What I do is, make a list of all the treatment the patient requires, with respect to their chief complaint, and then achieve the maximum corrections possible, with minimum intervention. Sometimes this may necessitate 1-2 crowns and that’s okay, because true minimally invasive dentistry, is achieving the maximum with minimum, and sometimes a whole gamut of functional issues can be addressed with just 1-2 crowns. (Fig 1)

3) CAD CAM dentistry gives better results.

CAD CAM dentistry has revolutionized the dental field.And it’s not necessary that you as the clinician have to own your own intra oral scanner, to get started with it. It can be done the old-fashioned way by sending impressions /casts to the lab, which is then scanned, instead of the patient’s mouth. The lab then generates an Exocad link, for the clinician, which I personally analyse in minute detail. Especially with regards to various aspects such as proclination correction, correction of rotation, diastema closure, the curve of Spee as well as the functional occlusion. I tweak this CAD several times, with the help of my technician, and I don’t proceed further until I’m satisfied. The best way to utilize the CAD is to print PMMA temps, which we can check on the patient. This makes a lot of difference in a clinician who’s starting out with his / her first smile design case. It helps patients visualise their final end result and gives the clinician a great confidence boost. This step is especially important because CAD crowns once milled, cannot incorporate major changes. The precise fit of CAD crowns is what they are revered for. But this can very well be a double-edged sword if we are not careful. (Fig 2)

4) Esthetics without function has no value.

This is an often-neglected aspect of smile design cases. Yes, esthetics is important but in the absence of function, it has no value. We must understand the mammoth role that anterior guidance plays in such cases. Failure to understand this, may well lead to wrong decision-making chair side, which will in turn lead to failure of the prosthesis. The clinician must have a very thorough understanding of steep versus shallow anterior guidance and which type of prosthesis is best suited where. And certain cases will require slight compromises in esthetics to achieve functional occlusion. When and where we compromise and by how much, is the key. (Fig 3)

5) Document your cases.

I cannot stress enough on the importance of this. A lot of clinicians think that documentation is terribly time consuming, and it’s meant only for celebrity dentists on social media. And that’s not true at all. Yes, documentation can be time consuming in the beginning, when you are not sure how to go about it, but just like everything else, there’s a learning curve involved. Once mastered, it requires only an extra minute or two, chair side, for every step. And its not necessary that one has to invest in an expensive DSLR camera for this purpose. Mobile Dental Photography also works. When we document our high-ticket cases-

• it helps us to go back and check up on things, we might have missed out on initially.
• It’s a must to convey the correct shade to the technician, for an accurate match.
• Most importantly, it gives us a record of how we sent the patient at conclusion versus how the patient comes back to us. This is very important to settle disputes because, how we conclude the case depends on us, but how and when the patient returns, is entirely dependant on them. (fFig 4)

6) Shade Gradation.

The chiclet white smile may be what the patient requests of us, but we have a duty to steering the patient towards a more natural smile. One that does not appear fake. A successful smile design is one, where close friends and family know that there is something different but cannot put their finger to it. Natural smiles have a shade gradation i.e., there is an increase in chroma progressively from the centrals to the canines. When we smile, all attention usually falls on the central incisors first and so it stands to reason that these teeth have the least chroma and the most value, thus appearing the brightest. This brightness or value decreases progressively from the centrals to the canines, with the canines having the most chroma and the least value. (Fig 5)