Aesthetic Dentistry of the Smile Line

The Clinical Problem ( Figs. 24.1A, 24.2A, 24.3A, 24.4A, 24.5A, and 24.6A )

1.
Bleaching of discolored teeth
2.
Improving tooth length to enhance the smile line
3.
Surgical correction of hard and soft tissue to correct anatomic disparities and subsequent dental procedure
4.
Restoring worn and missing spaces with crowns, veneers, and implants
5.
Treating a single tooth space with an implant, eliminating the need for a bridge, which involves a reduction of two adjacent teeth

FIGURE 24.1, (A) The aesthetic problem—short teeth, disparity in gums, and tipped teeth in the buckle corners. (B) Treatment technique—orthodontic tooth movement, with surgical soft and hard tissue shaping.

FIGURE 24.2, (A) The aesthetic problem—patient presented with a discolored tooth due to injury. (B) Treatment technique—included root canal and internal bleaching. This approach eliminates the need for a full crown.

FIGURE 24.3, (A) The aesthetic problem—smile line of the patient is compromised due to disproportionate growth of the upper and lower jaws and display of excessive gums. (B) Treatment technique—surgical correction included a Le Fort procedure and chin reduction, followed by orthodontic treatment. To enhance the lip line further, the patient elected to have veneers. This approach eliminated excessive gum visibility and improved the smile line.

FIGURE 24.4, (A) The aesthetic problem—a comprehensive oral reconstruction is indicated for a patient with a poor smile line due to discolored or worn teeth, old restorations, and missing spaces. (B) Treatment technique—a detailed analysis is needed to establish a treatment protocol. Soft and hard tissues are surgically contoured for an aesthetic smile line. Implants placed in missing spaces eliminate the need for a partial denture. Full mouth reconstruction was completed with veneers, crowns, and implant-supported restorations.

FIGURE 24.5, (A) The aesthetic problem—the traditional technique of restoring a missing space has been a three-unit bridge that requires the reduction of adjacent teeth. A single-unit implant is a good treatment option. (B) Treatment technique—a single-unit implant restored with a custom-made abutment and well-contoured crown is a successful long-term treatment of choice.

FIGURE 24.6, (A) The aesthetic problem—the management of an edentulous arch was a removable denture. A fixed prosthesis retained with screws to implants integrated in the bone eliminates the problems associated with removable dentures. (B) Treatment technique—four to six implants surgically placed in selective sites in the bone. Excellent osseointegration is observed. The implants provide excellent support for a screw-retained prosthesis. These restorations are greatly preferred by the patient and have universal acceptance. This technique replaces the use of removable dentures.

Denture wearers have an improved quality of life with an implant-supported fixed prosthesis. In facial cosmetic plastic surgery, the smile line plays a dominant role in a successful outcome. A plastic surgeon provides appearance-related facial surgery. The combined efforts of a plastic surgeon and dentist experienced in smile management result in a detailed pretreatment plan, with predictable outcomes.

Presurgical analysis by the dentist helps develop critically needed information for the surgeon, including a comprehensive analysis of the skeletal abnormalities of the upper and lower arches. These findings can assist the surgeon with treatment options related to management of a protruding maxilla or a retruded mandible. Detailed information can be obtained with regard to smile analysis, high lip line, and related issues, which can be corrected during surgery.

The role of the dentist in appearance-related dentistry and enhancement of a smile line has been well documented. Examples are presented in this chapter to help understand the synergy between the surgical skills of a plastic surgeon and the treatment that results in further enhancement rendered by a dentist. Sometimes, the dentistry is completed prior to surgery. In such situations, the dental work provides comprehensive details and landmarks that the plastic surgeon can use as references for the final surgical outcome.

Issues that detract from a pleasing smile include the following:

1.
Crooked broken teeth, spacing, or disparity in gum height
2.
Discolored teeth
3.
Disproportionate facial growth
4.
Bite collapse due to grinding, decay, or poor oral habits
5.
Facial collapse due to tooth and bone loss
6.
Poor smile due to missing spaces
7.
Facial collapse due to bone loss from extractions

Dental treatment options that enhance the appearance of an individual include the following:

1.
Space management with orthodontics, veneers, crowns, and implants
2.
Tooth whitening
3.
Oral maxillofacial surgery, including hard and soft tissue reduction

Overgrown gums (gummy smile) can be improved with recontouring of the soft and hard tissue.

4.
Worn and broken teeth, as well as missing spaces, restored with veneers, crowns, and implant-supported restorations
5.
Single missing tooth space restored with implant-supported crown
6.
Rehabilitation of patients with no teeth with implants and fixed prosthesis, resulting in excellent facial support and long-term benefits

Examples of dental treatments that can lead to excellent outcomes are presented here for a better understanding of the role of the dentist in appearance-related plastic surgery procedures.

Case 24.1: Resolving Space and Gummy Smile ( Fig. 24.1 )

The patient presented with an uneven and gummy smile, drifted teeth, and spaces present, which resulted in an unappealing smile. Soft and hard tissue recontouring was completed, followed by 10 porcelain veneers. The even coloration and gingival contour complements the smile and is well expressed in the patient's eyes.

A conservative approach to treatment of discolored teeth is conservative tooth shaping with ceramic veneers bonded to the teeth. This approach is minimally invasive, and the clinical outcome is very predictable. The dentist can control the size, shape, and color. In these situations, a higher quality of smile aesthetics is achieved by veneering a minimum of 10 teeth from premolar to premolar. A patient with a very wide smile may require coverage of the molars. Note that the buccal corridors are well filled and complement the lip line.

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