CHAPTER 9: ADDITIONAL CONSERVATIVE ESTHETIC PROCEDURES PART I

What improvements in dentistry have expanded conservative esthetic treatment possibilities?

A: Significant advances in tooth-colored restorative materials, color matching, and adhesive techniques.

Q: Why is conservative esthetic dentistry considered the “art” of dentistry?

A: It emphasizes creativity, imagination, and artistic expression, producing immediate esthetic improvements.

no local anesthesia needed because reshaping is restricted to enamel

Q: What did Goldstein say about esthetic dentistry?

A: “Esthetic dentistry is the art of dentistry in its purest form.”

Q: Why is a beautiful, natural smile considered one of a person’s greatest assets?

A: It enhances appearance, boosts confidence, and positively affects personality and social life.

basic artistic elements in conservative esthetic dentistry

Shape or form, symmetry and proportionality, position and alignment, surface texture, color, and translucency.

Trapezoidal

the typical crown outline of an incisor when viewed from the facial or lingual position

kind of surface texture is typical of youthful teeth

Pronounced perikymata, developmental depressions, and varied reflective surfaces.

features typically characterize a youthful smile

Rounded incisal angles, open incisal/facial embrasures, and softened facial line angles.

smile characteristics are typical of older individuals with attrition

Closed incisal embrasures and more prominent (less rounded) incisal angles and Sharp incisal angles

surface texture is typical of older teeth

Smoother surfaces due to attrition and wear, with less pronounced developmental anatomy.

cosmetic contouring

Minor reshaping of enamel (e.g., rounding incisal angles, opening embrasures, reducing prominent line angles) to produce a more youthful appearance

significant generalized esthetic changes be achieved

When treating all anterior teeth (and sometimes first premolars) visible in the smile, especially with full-coverage facial restorations like veneers.

subtle features should be examined on a contralateral tooth when restoring a single anterior tooth

Developmental depressions, embrasure form, prominences, and other unique contours.

How do light and shadow affect tooth esthetics

Prominent contours reflect more light and appear more noticeable, while depressions create shadows and appear less conspicuous.

How can contouring be used to make a tooth appear narrower

Move mesiofacial and distofacial line angles closer together and bring developmental depressions closer.

How can contouring be used to make a tooth appear wider

Place line angles and developmental depressions farther apart

What contour changes make a tooth appear shorter

Emphasizing horizontal elements, moving gingival height of contour incisally, and shifting incisal height of contour gingivally.

What contour changes make a tooth appear longer

Moving gingival and incisal heights of contour farther apart and emphasizing vertical elements.

How illusionary techniques useful in diastema closure

By maintaining original line angle positions and using contouring to make increased tooth width less noticeable.

main esthetic challenge when restoring a single anterior tooth

Achieving a high degree of realism to match the natural surrounding teeth.

What combination of techniques can control tooth proportions in diastema closures with veneers

Enhancing vertical elements and deemphasizing horizontal features to balance the apparent dimensions.

governs the overall esthetic appearance of a smile

Symmetry and proportionality of the teeth.

How do asymmetry and disproportion affect a smile

They disrupt balance and harmony, reducing esthetic appeal.

When can dental symmetry be maintained?

A: If contralateral teeth are equivalent in size and form.

dental caliper

instrument should be used to measure tooth widths in esthetic procedures like diastema closure

must be mirrored across the midline to ensure symmetric central incisors

A: The mesial contours, incisal embrasures, and gingival embrasures.

The golden proportion

geometric concept has been applied to dental esthetics for proportionality

the golden proportion in dental esthetics

A: Each tooth, starting from the midline, is about 60% (exact ratio 0.618) of the apparent width of the tooth immediately mesial to it.

A: Only about 17% of people naturally exhibit it.

How common is the golden proportion in natural smiles, according to Preston?

About 70% proportion

recurring proportion did Ward’s survey of dentists suggest is more esthetic than 61.8%

0.85 in men and 0.86 in women

average width-to-length ratio of maxillary central incisors found by Sterrett et al.

0.76 in men and 0.79 in women

the average width-to-length ratios of maxillary lateral incisors found by Sterrett et al

0.87 for worn incisors and 0.78 for unworn incisors

What did Magne et al. report for width-to-length ratios of maxillary central incisors

About 0.80 for central incisors and 0.75 for lateral incisors

the accepted ideal width-to-length ratio for maxillary central incisors and lateral incisors

How can altered passive eruption affect width-to-length ratios of central incisors

It can produce a square (1:1 ratio) appearance, corrected by crown lengthening to restore an ideal 0.80 ratio.

Why must dentists avoid narrow, elongated, or short-wide central incisors?

A: Because central incisors are the dominant focal point of the smile, and distorted proportions reduce esthetics.

What role do interdisciplinary treatments play in achieving proper esthetic proportions?

Orthodontics and periodontics (e.g., crown lengthening) are often essential for ideal esthetic results.

Why is surface texture significant in conservative esthetic dentistry

Because it affects how light reflects off teeth, influencing realism and natural appearance.

Why is translucency critical in anterior restorations

It creates depth, vitality, and a natural blending with surrounding teeth.

The degree to which light penetrates into a tooth or restoration before being reflected outward.

happens if a restoration lacks translucency:

The restoration appears flat, opaque, and artificial

Q: Why must dentists balance surface texture with polishability

Over-texturing can trap plaque, while over-polishing may eliminate natural anatomy.

conservative options exist if orthodontic treatment is impractical or unaffordable

Composite augmentation or full facial veneers (composite or porcelain).

type of preparation is recommended when using veneers for rotated teeth

Intraenamel preparation with greater reduction in the area of prominence

How can mild linguoversion be corrected conservatively

By augmentation with full facial veneers (direct composite or indirect composite/porcelain).

must be maintained when restoring malposed teeth with veneers

Physiologic gingival contours and a proper emergence profile to avoid gingival irritation.

Why should excessively thick incisal edges be avoided in restorations

They compromise function and esthetics; proper incisal contour ensures functional occlusion.

limited lingual enamel reduction

appropriate in malposed teeth treatment If occlusion allows, to reduce faciolingual dimension of the incisal portion—without altering areas in protrusive contact.

determines the character and individuality of teeth

surface texture and existing characteristics

Why are restorations without surface characterizations rarely indicated

they look unnatural and fail to blend with surrounding teeth.

How do natural tooth surfaces reflect light?

They break up light and reflect it in multiple directions.

Color

artistic element considered the most complex and least understood

Value

element of color is often the basis of some modern shade guide

Thick enamel → lighter teeth.

How does enamel thickness affect tooth color in young individuals

aging-related changes affect tooth color

Enamel wear exposes dentin → teeth look darker; incisal edges darken from thinning enamel or attrition; cervical areas darken due to abrasion.

the most accurate method for shade selection

Apply and cure a small amount of the restorative material directly on the tooth before isolation.

Metamerism

describes how different light sources produce different color perceptions

causes color fatigue in shade selection

Extended viewing of a tooth site reduces sensitivity to yellow-orange shades

How light normally interact with natural teeth

Light penetrates through enamel into dentin before reflecting outward, giving teeth esthetic vitality.

The restoration loses esthetic vitality and looks less natural when light penetration is shallow

Why do opaque resin media reduce esthetic vitality

They mask stains but block light penetration

color modifiers (tints) used for in esthetic dentistry

To create illusions of translucency, reduce brightness of stains, or add characterizations.

How can yellow intrinsic stains be toned down with color modifiers

A: Apply violet (the complementary color of yellow) to reduce intensity.

Besides translucency simulation, what else can color modifiers reproduce

A: Maverick colors, crack lines, and surface spots.

Who emphasized the link between esthetics and function in dentistry?

Dawson — “The better the esthetics, the better the function is likely to be and vice versa.”

Why is finishing the gingival areas of restorations important

To remove excess material and avoid irritation.

must be avoided in restoration emergence profiles

Impingement on gingival tissue — emergence angles must be physiologic.

procedures are included under conservative alteration of contour and contact

Reshaping natural teeth, correcting embrasures, and closing diastemas

Attrition of the incisal edges

causes closed incisal embrasures and angular incisal edges

common causes of fractured or worn incisal edges

Accidents, attrition, and poor dental habits (e.g., biting fingernails, holding objects with teeth)

tools can help patients visualize the esthetic improvement before reshaping

Photographs, study models, line drawings, or esthetic imaging devices

instruments are used for cosmetic reshaping and polishing of enamel?

Diamond instruments, abrasive disks, and abrasive points

Protrusive function

occlusal consideration that must be checked before incisal reshaping to avoid eliminating essential occlusal contact

advantage do rounded incisal edges have over sharp edges

They are less likely to chip or fracture

esthetic problem can occur with anterior embrasures

They can appear too open due to tooth shape or position in the arch.

often happens when permanent lateral incisors are congenitally missing

Canines or posterior teeth drift mesially, or orthodontic closure leaves embrasures too open.

canines can be modified to resemble lateral incisors By reshaping their facial surface and cusp angle

Composite resin

material is commonly added to correct open embrasures

composite mockup

Temporarily adding unetched/unbonded composite to fill the embrasure to simulate the final result for the patient.

useful aids in helping patients understand embrasure correction

Line drawings, esthetic imaging, photographs of similar cases, or composite mockups.

instruments used to prepare overly convex enamel or roughen the surface before bonding

A coarse, flame-shaped diamond and possibly abrasive strips with a wedge.

How is the adjacent tooth protected during etching

By inserting a polyester strip or Teflon tape.

bonding sequence for embrasure correction with composite

Roughen enamel → place protective strip → acid etch → rinse/dry → position contoured strip → insert composite → polymerize

common etiologies of diastema

• Prominent labial frenum with fibers preventing approximation of incisors

• Congenitally missing, undersized, or malformed teeth

• Interarch tooth size discrepancy (Bolton discrepancy)

• Supernumerary teeth

• Heredity

• Tongue thrusting

• Periodontal disease

• Posterior bite collapse

Traditional treatment options for diastema closure?

Surgical, periodontal, orthodontic, and prosthetic procedures.

a more practical, conservative method of diastema correction

Composite augmentation of proximal surfaces via adhesive procedures

Preliminary diagnostic aids before diastema correction with composite

Line drawings, photos, computer imaging, study models with filled spaces, or mockups using wax/composite (unetched).

Boley gauge or caliper

tool is used to measure the diastema and tooth width

cotton rolls

preferred over rubber dam in diastema closure bc They allow better evaluation of restoration contour relative to gingival tissues

purpose of gingival retraction cord in diastema correction

Retracts soft tissue, prevents fluid seepage, and allows composite extension slightly below gingival crest for natural contour.

Coarse, flame-shaped diamond bur

bur is used to roughen proximal surfaces for composite retention

Approximately 0.5 mm beyond

How far should enamel be etched beyond the prepared surface

the main role of the polyester strip during restoration

Acts as a matrix to shape the composite, extends below gingival crest, and prevents bonding to adjacent teeth

Why should the first restoration be slightly overcontoured

To allow finishing and shaping to ideal contour after polymerization.

instruments are used for contouring and finishing composite in diastema closure

Carbide finishing burs, fine diamonds, abrasive discs, and finishing strips.

How can a tight proximal contact be achieved when restoring the second tooth

By displacing the tooth distally with fingers while holding the matrix against the first restoration.

main conservative treatment options for discolored teeth

Removal of surface stains, bleaching, microabrasion/macroabrasion, veneering, and porcelain crowns.

classifications of tooth discolorations

extrinsic (external) or intrinsic (internal)

common causes of extrinsic discolorations in young patients

• Remnants of Nasmyth membrane

• Poor oral hygiene

• Existing restorations

• Gingival bleeding

• Plaque accumulation

• Eating habits

• Chromogenic microorganisms

How do extrinsic stains typically appear in older patients

Brown, black, or gray stains near gingival margins.

lifestyle factors contribute to extrinsic stains

Coffee, tea, chromogenic foods/medications, and tobacco use.

betel nut juice

an cultural example of intentional tooth staining

In Southeast Asia, women traditionally stained teeth as a sign of beauty

Teeth were pre-treated with weak acids (e.g., citrus juice) to demineralize enamel before applying betel nut juice.

Professional prophylaxis (cleaning)

routine treatment removes most surface stains

this alone cannot correct discoloration in a superficial stains on tooth-colored restorations or in decalcified enamel areas 

conservative treatments are available for intrinsic discolorations

Bleaching, microabrasion, macroabrasion, and veneers