JPOR-281; No. of Pages 7 journal of prosthodontic research xxx (2015) xxx–xxx
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End points and assessments in esthetic dental treatment Yuichi Ishida DDS, PhD*, Keiko Fujimoto DDS, Nobuaki Higaki DDS, Takaharu Goto DDS, PhD, Tetsuo Ichikawa DDS, PhD Department of Oral and Maxillofacial Prosthodontics, Institute of Health Biosciences, Tokushima University, Japan
article info
abstract
Article history:
Purpose: There are two key considerations for successful esthetic dental treatments. This
Received 31 March 2015
article systematically describes the two key considerations: the end points of esthetic dental
Received in revised form
treatments and assessments of esthetic outcomes, which are also important for acquiring
11 May 2015
clinical skill in esthetic dental treatments.
Accepted 12 May 2015
Study selection: The end point and assessment of esthetic dental treatment were discussed
Available online xxx
through literature reviews and clinical practices. Results: Before designing a treatment plan, the end point of dental treatment should be
Keywords:
established. The section entitled ‘‘End point of esthetic dental treatment’’ discusses treat-
End point
ments for maxillary anterior teeth and the restoration of facial profile with prostheses. The
Assessment
process of assessing treatment outcomes entitled ‘‘Assessments of esthetic dental treat-
Esthetic dental treatment
ment’’ discusses objective and subjective evaluation methods. Conclusions: Practitioners should reach an agreement regarding desired end points with patients through medical interviews, and continuing improvements and developments of esthetic assessments are required to raise the therapeutic level of esthetic dental treatments. # 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . End point of esthetic dental treatment . . . . . . . . . . . . . . 2.1. Esthetic harmony with existing teeth . . . . . . . . . . 2.2. Ideal esthetic criteria for maxillary anterior teeth 2.3. New SPA factors . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Golden proportion . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Esthetic balance of the facial profile . . . . . . . . . . . Assessments of esthetic dental treatment . . . . . . . . . . . 3.1. Objective evaluation . . . . . . . . . . . . . . . . . . . . . . . 3.2. Subjective method . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: Department of Oral and Maxillofacial Prosthodontics, Institute of Health Biosciences, Tokushima University, 3-18-15 Kuramoto, Tokushima 770-8504, Japan. Tel.: +81 88 633 7347; fax: +81 88 633 7461. E-mail address: [email protected] (Y. Ishida). http://dx.doi.org/10.1016/j.jpor.2015.05.002 1883-1958/# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Please cite this article in press as: Ishida Y, et al. End points and assessments in esthetic dental treatment. J Prosthodont Res (2015), http:// dx.doi.org/10.1016/j.jpor.2015.05.002
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4.
1.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Prosthodontics, also known as prosthetic dentistry, is the area of dentistry that focuses on restoration of partial and total edentulism and alveolar bone defects using biomaterials. Its focus is on improvement in oral function and esthetics. In prosthetic restoration of the anterior upper region, esthetic considerations (color and morphology of the teeth and gingivae and facial symmetry) are taken into account because of their influence upon the patient’s quality of life (QoL). Mori et al. [1] reported the results of a questionnaire given to 1457 workers at a major company, indicating that a smile and white teeth are very important to business relationships and that during communication, the gaze is drawn first to the eyes and then to the mouth. In a QoL questionnaire related to oral health (Oral Health Impact Profile [OHIP J-54], Japan Prosthodontic Society) [2], seven of the 54 items relate to esthetic factors; the questionnaire suggests that esthetic considerations of the mouth greatly affect patients’ QoL. General dentists are aware that esthetic dental treatment is a required skill. Esthetic restorations are not made of ceramic but are designed to create morphological and color harmony with the natural teeth, gingivae, lips, and face. In addition, restorations must maintain oral function and esthetics in the long term. Disciplines including prosthodontics, periodontology, oral surgery, orthodontics, and dental technology are involved in accomplishing the treatment goal. Because the esthetic conception is abstract, formulating a concrete treatment goal and communicating it between dentists and patients is difficult; carrying out esthetic treatments may also be difficult. The saying ‘‘dentistry is an art and science’’ is well known [3]. Science is a systematic action that organizes knowledge in the verifiable and logical form. Art is not just painting and drawing; it is the action of creating to fix various human activities and is not explained by theory and reason. Esthetic dentistry involves the field of art. Understandably, esthetic dentistry has no clear clinical guidelines. Even so, we must attempt to bring esthetic dentistry from the field of art to that of science to widely disseminate the knowledge and skill of esthetic dentistry and to enhance the treatment outcomes for general dentists. This article systematically describes the end points of esthetic treatments and assessments of esthetic outcome, which are important for acquiring skill in esthetic dental treatments.
2.
End point of esthetic dental treatment
Planning dental treatments in advance is indispensable in all clinical cases. Problems to be solved with dental treatment, including esthetics, should initially be determined through medical interviews and clinical examinations, and an end point or goal of treatment should be established. ‘‘Top-down treatment,’’ in which the treatment plan is focused on the
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desired end point, is a basic principle in prosthetic dentistry and should also be used in esthetic dental treatment. In this chapter, we discuss esthetic end points concerning the maxillary anterior teeth and facial profile.
2.1.
Esthetic harmony with existing teeth
With the maxillary anterior teeth, the end point of esthetic dental treatment is a restoration that is indistinguishable from the existing teeth and gums. If only a few teeth are missing or defective and the adjacent teeth have an appropriate form and color to use as a reference, the restoration should imitate them in form, color, surface texture, translucency, and characterization. Characteristics of the gums, such as the level of soft-tissue margin, soft-tissue contour, alveolar process, and soft-tissue color, should also be considered.
2.2.
Ideal esthetic criteria for maxillary anterior teeth
If all or most of the maxillary anterior teeth are missing or defective, determining the end point of esthetic dental treatments can be very complicated, but the possibilities of prosthetic design (tooth form, color, and arrangement) are greatly expanded. In these patients, the end point of esthetic treatment should be based on previously reported references for ideal esthetic anterior tooth conditions. Ideal esthetic criteria for the maxillary anterior teeth have been reported as follows (Table 1). The center of the dental arch matches the center of the facial surface, and the outlines of the teeth and gums are bilaterally symmetrical to the center of dentition [4]. The width to height ratio of the central incisor is ideally 1:0.75–0.8; this proportion is more important for esthetics than is the morphological relationship between the central and lateral incisors [5]. The ideal mesiolingual inclination of the central incisor is slightly distal, the laterals are inclined distally more than central incisors, and canines are more distally [6,7]. The lateral incisors is 1.0 to 1.5 mm above the level of the central incisors [8], and the incisal edge line of the anterior maxillary teeth approaches the lower lip line during a smile [9,10]. The ideal interproximal contact location of the central incisors is higher than the central-lateral or lateral-canine contact location. The interproximal contact of the anterior maxillary teeth should approach the lower lip line during a smile [6]. The ideal soft-tissue margin of the canines is higher than or the same as those of the central incisors, and the softtissue margin of the lateral incisors is lower than or the same as those of the central incisors [11]. The deepest position of the ideal soft-tissue contour is slightly distal to the center of the tooth [12] (Table 2).
2.3.
New SPA factors
In 1965, Frush and Fisher [13–15] proposed the concept of dentogenics, in which the selection and arrangement of artificial teeth and the festoon should be based on the sex,
Please cite this article in press as: Ishida Y, et al. End points and assessments in esthetic dental treatment. J Prosthodont Res (2015), http:// dx.doi.org/10.1016/j.jpor.2015.05.002
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Table 1 – Ideal esthetic criteria for the maxillary anterior teeth.
Table 2 – Ideal interproximal contact location and softtissue form.
Esthetic factor
Esthetic factor
Esthetic criteria
The center of the dental arch The outlines of the teeth and gums The width to height ratio of the central incisor
To match the center of the facial surface Bilaterally symmetrical to the center of dentition 1:0.75–0.8
The mesiolingual inclination
The central incisor is slightly distal The lateral incisor is more distally than central incisor The canine is more distally than lateral incisor
The level of the anterior teeth
The lateral incisors is 1.0–1.5 mm above the central incisors The incisal edge line approaches the lower lip line during a smile
personality, and age (SPA factors) of the patient. They recommend a square shape for heavily-muscled men, a rounded shape for women, and teeth showing wear and deep color for elderly patients. Sex, personality, and age are often taken into consideration when designing removable dentures and are also applied to crowns and fixed partial denture prostheses. It is very important to satisfy each patient’s esthetic demands and to increase satisfaction with esthetic treatments. With the current social trend toward anti-aging treatments, patients increasingly request esthetically pleasing prostheses with a whiter color. Esthetic dental treatment is often expensive, and patients expect successful long-term results (prognosis). When results are poor, we fall into difficulties. A new definition of SPA factors needed for contemporary esthetic dental treatment may be satisfaction, prognosis, and anti-aging, rather than sex, personality, and age.
2.4.
Golden proportion
The golden proportion, in which everyone senses beauty and harmony instinctively, has been used as an esthetic guideline in both art and science. The golden proportion is the ratio between the length of a side of an equilateral pentagon to that pffiffiffi of its diagonal, which is 1:(1 þ 5)/2, or 1:1.618. The golden proportion has also been used in the practice of esthetic dentistry. For example, the dental anterior arch is considered most beautiful if the proportions of the maxillary lateral incisor width to central incisor width and of the maxillary canine width to lateral incisor width are equal to the golden proportion in the frontal side view [16] (Fig. 1). This proportion is based not on the anatomical width but on the frontal view.
2.5.
Esthetic balance of the facial profile
Esthetic dental treatments must take into account the balance of the facial profile as well as esthetic factors of prosthetics and gums. Matthews [6] reported that in a well-balanced facial profile, the distances between the hairline and the upper
Esthetic criteria
The interproximal contact location
The central incisors is higher than the central-lateral contact location The central-lateral incisors is higher than the lateral-canine contact location
The soft-tissue margin
The canines is higher than or the same as those of the central incisors The lateral incisors is lower than or the same as those of the central incisors
The deepest position of the ideal soft-tissue contour
Slightly distal to the center of the tooth
eyebrow margins, the upper eyebrow margins and the tip of the nose, and the tip of the nose and the chin (menton) are nearly identical. Ricketts [17,18] reported that the measurements between the external canthus, subnasale, angulus oris, and menton, which divide the face into three parts, are the golden proportions in an ideal face profile (Fig. 2). The overall facial profile cannot be altered solely by dental treatment; however, the vertical dimension, which affects much of the lower part of the facial profile, can be altered by dental treatment. The degree to which the maxillary anterior teeth are visible with the lips at rest must be considered when determining their form and position. The standard position of the incisal edge of the maxillary anterior teeth is approximately 2 to 4 mm below the bottom of the upper lip at rest [19,20]. However, it has also been reported that the position of the edge of the maxillary anterior teeth depends on age, sex, and lip tension and may range from 1 to 5 mm below the bottom of the upper lip [20,21]. Moreover, the mandibular anterior teeth become more exposed in elderly patients. Although the exposure of the anterior teeth differs widely among patients, the usual amount of exposure considering their sex and age must be taken into account [21]. The bottom line of the upper lip in the laughing position is referred to as the smile line. The positional relationship of the smile line and the maxillary anterior teeth influences the desired end point. Smile lines are classified into three types: low smile line, in which gingival embrasures and cementoenamel junction are not visible, ‘‘average smile line’’ in which only gingival embrasures are visible and ‘‘high smile line’’ in which gingival embrasures and cementoenamel junction are visible. Tjan et al. [10] reported that the ratio of low smile line was 20.5%, that of average smile line was 65.0% and that of high smile line was 10.5% and also reported that these ratio differed in each population, such as the races. In the case of high smile line in which gingival embrasures and cementoenamel junction visible, the esthetic dental treatment become to be more difficult because the patients demand improvement of gingival appearance as treatment outcome. Therefore, careful attention must be paid to the position of the smile line before the treatment.
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Fig. 1 – Width of maxillary anterior teeth and golden proportion. The ratio between the length of black line to that of white line is 1.618:1.
Fig. 2 – Balance of facial profile and golden proportion. The ratio between the length of black line to that of white line is 1.618:1.
profile, the upper and lower lips should both coincide with the E-line [24,25]. Results of a questionnaire of 150 people over 15 years of age also indicated that the upper and lower lips should be positioned approximately 1–4 mm posterior to the E-line [26], suggesting that Westernized facial profiles are becoming more popular in the Japanese population [27].
3.
Fig. 3 – Esthetic line.
It is well known that the ‘‘esthetic line’’, which shows the straight line connecting the Pogonion on the mucous membranes to tip of the nose [22], is used as to determine the esthetic end point for the lateral facial profile (Fig. 3). Reports indicate that in Japanese people, the upper lip coincides with the E-line and the lower lip is located outside the E-line [23]; however, for an esthetically pleasing facial
Assessments of esthetic dental treatment
The process of assessing treatment outcomes is essential for determining the success of esthetic dentistry treatment. Assessment consists of objective evaluation by the dentist and subjective evaluation by the patient. Objective evaluation is useful for assessing relative outcomes among patients; however, variations can exist between dentists. Subjective evaluation, on the other hand, is less useful for assessing relative outcomes but can be effective for assessing the absolute outcome. This section describes objective and subjective evaluations for assessing esthetic dental treatment.
3.1.
Objective evaluation
The White Esthetic Score (WES) [28] (Fig. 4) is used to objectively evaluate esthetic treatment outcomes of anterior single-tooth implants in the esthetic zone. The WES comprises tooth form, tooth volume/outline, color, surface texture, and translucency. A score of 2, 1, or 0 is assigned to all five
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Major Discrepancy Minor Discrepancy No Discrepancy
1: Tooth Form
0
1
2
2: Outline & Volume
0
1
2
3: Color (hue & value)
0
1
2
4: Surface Texture
0
1
2
5: Translucency & Characterizaon
0
1
2
Maximum Score: 10 Fig. 4 – White Esthetic Scores (WES).
1: Mesial papilla
0 Absent
1 Incomplete
2 Complete
2: Distal papilla
Absent
Incomplete
Complete
3: Level of so-ssue margin
>2 mm
1-2 mm
1< mm
4: So-ssue contour
Unnatural
Fairly natural
Natural
5: Alveolar process
Obvious
Slight
None
6: So-ssue color
Obvious difference
Moderate difference
No difference
7: So-ssue texture
Obvious difference
Moderate difference
No difference
Maximum Score: 14 Fig. 5 – Pink Esthetic Scores (PES).
elements by comparing to the other side tooth and assessed for complete agreement (score 2), incomplete agreement (score 1), or disagreement (score 0). The Pink Esthetic Score (PES) [29] (Fig. 5) specifically focuses on the following seven variables for gingival aspects of the implant site: mesial papilla, distal papilla, level of soft-tissue margin, soft-tissue contour, alveolar process, soft-tissue color, and soft-tissue texture. A score of 2, 1, or 0 is also assigned to all seven parameters. There is no evaluation item regarding the gingival biotype in this assessment. It will be because the gingival biotype affects the response of gingival treatment and the longevity of esthetic treatment, not the esthetic end point itself. Differences in the WES and PES among dentists may be caused by unclear assessment criteria or by too little grades. Fuhauser et al. reported that orthodontists were the most critical among twenty observers (five prosthodontists, five oral surgeons, five orthodontists, and five dental students) who assessed the PES of the soft tissue of 30 single-tooth implant crowns [29]. Cho et al. mentioned that periodontists were the most generous and prosthodontists were the most critical of eight observers (two periodontists, two prosthodontists, two orthodontists, and two dental students) who assessed the PES
and WES of 41 implant-supported single restorations [30]. Careful attention should be paid to the assessments of different observers, especially in different fields, when using the PES and WES.
3.2.
Subjective method
The OHIP [31] is a valuable subjective indicator of oral health. The Japanese version of the OHIP (OHIP-J), with 54 items, is derived from the OHIP [2]. For each OHIP-J item, participants are asked to rate the frequency of their experiences on a scale of 0 (never) to 4 (very often) for eight parameters: ‘‘functional limitation,’’ ‘‘physical pain,’’ ‘‘psychological discomfort,’’ ‘‘physical disability,’’ ‘‘psychological disability,’’ ‘‘social disability,’’ ‘‘handicap,’’ and ‘‘additional Japanese items.’’ The 54 items of OHIP-J include seven that estimate esthetics; however, the OHIP-J has no parameter specifically focusing on esthetics. Therefore, the OHIP-J has little validity for assessing the direct outcome of esthetic dental treatments. The visual analog scale (VAS) [32] is another valid and reliable instrument for measuring subjective outcomes. Many studies have reported the subjective outcome of ‘‘patient acute pain’’ as measured by the VAS. Patients are asked to
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Dental Self-Confidence I am proud of my teeth. I like to show my teeth when I smile. I am pleased when I see my teeth in the mirror. My teeth are aracve to others. I am sasfied with the appearance of my teeth. I find my tooth posion to be very nice.
Social Impact I hold myself back when I smile so my teeth don’t show so much. If I don’t know people well, I am somemes concerned what they might think about my teeth. I’m afraid other people could make offensive remarks about my teeth. I am somewhat inhibited in social contacts because of my teeth. I somemes catch myself holding my hand in front of my mouth to hide my teeth. Somemes I think people are staring at my teeth.
Remarks about my teeth irritate me even when they are meant jokingly. I somemes worry about what members of the opposite sex think about my teeth.
Psychological Impact I envy the nice teeth of other people. I am somewhat distressed when I see other people’s teeth. Somemes I am somewhat unhappy about the appearance of my teeth. I think most people I know have nicer teeth than I do. I feel bad when I think about what my teeth look like. I wish my teeth looked beer.
Aesthec Concern I don’t like to see my teeth in the mirror. I don’t like to see my teeth in photographs. I don’t like to see my teeth when I look at a video of myself.
Fig. 6 – Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ).
mark their pain intensity on a 10-cm ruler. A mark at 0 cm (a VAS value of 0) signifies ‘‘no pain at all’’; a mark at 10 cm (a VAS value of 100) signifies ‘‘the worst pain possible.’’ The VAS scale has been applied to outcomes of esthetic dental treatment as well as to pain. Some studies have used the VAS to report esthetic outcomes including teeth alignment, color, and morphology of the teeth and the shape of the gingivae. In these cases, 0 cm on the scale signifies ‘‘not satisfied at all’’ and 10 cm signifies ‘‘very satisfied.’’ The VAS scale has high reliability and reproducibility [5,33–36]; however, it requires careful attention to take each question a different way among patients. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), reported by Ulrich Klages et al. [37], supplies very valuable information concerning esthetics after orthodontic treatment (Fig. 6). The PIDAQ contains 23 items and four subscales that represent esthetic concerns in three items, psychological impact in six items, social impact in eight items, and dental self-confidence in six items. For each item, participants are asked to respond with scores of 0 (not at all), 1 (a little), 2 (somewhat), 3 (strongly), or 4 (very strongly). If the patient has high satisfaction with esthetics, the PIDAQ score for dental self-confidence will be high, and the scores for the other subscales will be low. Few studies concerning the outcome of esthetic dental treatments using the PIDAQ have been reported [38]. However, the PIDAQ has recently been translated into other languages [39–42], so it may become effective for evaluating the esthetic outcome not only of orthodontic treatment but also of prosthodontic treatment.
4.
Conclusion
There are two key considerations for successful esthetic dental treatments. One is that esthetics is a value judgment
that is not universal and depends on various factors such as age, race, and district of residence. It may be difficult to understand a patient’s goals for esthetic dental treatment. The best way to reach the treatment goal is to understand the end points that we have proposed in this article and reach an agreement with the patient through a medical interview. The other consideration is that the end point and treatment plan is greatly influenced by each patient’s wishes and financial resources and the dental team’s treatment skills and environment. We believe that treatment skills are improved through the PDCA (Plan-Do-Check-Act) cycle. Appropriate assessments in the PDCA cycle are required to improve treatment skills. Although we have discussed some subjective and objective assessments in this article, there is no gold standard for esthetic assessment. Practitioners should understand the characteristics of each assessment tool and use the one most appropriate for each situation. Continuing improvements and developments of esthetic assessments are required to raise the therapeutic level of esthetic dental treatments.
Conflict of interest No potential conflicts of interest were disclosed.
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[25] Ito K, Ueki S, Tabe T, Yamauchi K. A consideration with stabilized position of incisors after orthodontic treatment. Orthodontic waves 1977;36:212–30. [26] Shimomura T, Ioi H, Nakata S, Amy C. Evaluation of wellbalanced lip position by Japanese orthodontic patients. Am J Orthod Dentofacial Orthop 2011;139:291–7. [27] Miyajima K, McNamara JA, Kimura T, Murata S, Iizuka T. Craniofacial structure of Japanese and European-American adults with normal occlusions and well-balanced faces. Am J Orthod Dentofacial Orthop 1996;110:431–8. [28] Belser UG, Grutter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80:140–51. [29] Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek D. Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005;16:639–44. [30] Cho HL, Lee JK, Um HS, Chang BS. Esthetic evaluation of maxillary single-tooth implants in the esthetic zone. J Periodontal Implant Sci 2010;40:188–93. [31] Slade GD, Spencer AJ. Development and evaluation of the Oral Health Impact Profile. Community Dent Health 1994;11:3–11. [32] Keel KD. The pain chart. Lancet 1948;2:6–8. [33] Brunzel S, Kern M, Freitag S, Wolfart S. Aesthetic effect of minor changes in incisor angulation: an Internet evaluation. J Oral Rehabil 2006;33:430–5. [34] Nikgoo A, Alavi K, Alavi K, Mirfazaelian A. Assessment to the golden ratio in pleasing smiles. World J Orthod 2009;10:224–8. [35] Schabel BJ, McNmara JA, Franchi L, Baccetti T. Q-sort assessment vs visual analog scale in the evaluation of smile esthetics. Am J Orthod Dentofacial Orthop 2009;135:61–71. [36] Faure JC, Rieffe C, Maltha JC. The influence of different facial components on facial aesthetics. Eur J Orthod 2002;24:1–7. [37] Ulrich K, Nadine C, Heinrich W, Andrej Z. Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults. Eur J Orthod 2006;28:103–11. [38] Chen P, Yu S, Zhu G. The psychosocial impacts of implantation on the dental aesthetics of missing anterior teeth patients. Br Dent J 2012;214:105. [39] Bucci R, Rongo R, Zito E, Galeotti A, Valletta R, D’Anto V. Cross-cultural adaptation and validation of the Italian Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ). Qual Life Res 2015;24:747–52. [40] Singh VP, Singh R. Translation and validation of a Nepalese of the Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ). J Orthod 2014;41:6–12. [41] Spali S, Lajnert V, Ivankovic L. The psychosocial impact of dental aesthetic questionnaire-translation and crosscultural validation in Croatia. Qual Life Res 2014;23:1267–71. [42] Nqom PI, Attebi P, Diouf JS, Badiane A, Diaqne F. Translation and cultural adaptation of a French version of the Psychosocial Impact of Dental Aesthetic Questionnaire (PIDAQ). Orthod Fr 2013;84:319–31.
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Review
End points and assessments in esthetic dental treatment Yuichi Ishida DDS, PhD*, Keiko Fujimoto DDS, Nobuaki Higaki DDS, Takaharu Goto DDS, PhD, Tetsuo Ichikawa DDS, PhD Department of Oral and Maxillofacial Prosthodontics, Institute of Health Biosciences, Tokushima University, Japan
article info
abstract
Article history:
Purpose: There are two key considerations for successful esthetic dental treatments. This
Received 31 March 2015
article systematically describes the two key considerations: the end points of esthetic dental
Received in revised form
treatments and assessments of esthetic outcomes, which are also important for acquiring
11 May 2015
clinical skill in esthetic dental treatments.
Accepted 12 May 2015
Study selection: The end point and assessment of esthetic dental treatment were discussed
Available online xxx
through literature reviews and clinical practices. Results: Before designing a treatment plan, the end point of dental treatment should be
Keywords:
established. The section entitled ‘‘End point of esthetic dental treatment’’ discusses treat-
End point
ments for maxillary anterior teeth and the restoration of facial profile with prostheses. The
Assessment
process of assessing treatment outcomes entitled ‘‘Assessments of esthetic dental treat-
Esthetic dental treatment
ment’’ discusses objective and subjective evaluation methods. Conclusions: Practitioners should reach an agreement regarding desired end points with patients through medical interviews, and continuing improvements and developments of esthetic assessments are required to raise the therapeutic level of esthetic dental treatments. # 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . End point of esthetic dental treatment . . . . . . . . . . . . . . 2.1. Esthetic harmony with existing teeth . . . . . . . . . . 2.2. Ideal esthetic criteria for maxillary anterior teeth 2.3. New SPA factors . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Golden proportion . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Esthetic balance of the facial profile . . . . . . . . . . . Assessments of esthetic dental treatment . . . . . . . . . . . 3.1. Objective evaluation . . . . . . . . . . . . . . . . . . . . . . . 3.2. Subjective method . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: Department of Oral and Maxillofacial Prosthodontics, Institute of Health Biosciences, Tokushima University, 3-18-15 Kuramoto, Tokushima 770-8504, Japan. Tel.: +81 88 633 7347; fax: +81 88 633 7461. E-mail address: [email protected] (Y. Ishida). http://dx.doi.org/10.1016/j.jpor.2015.05.002 1883-1958/# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Please cite this article in press as: Ishida Y, et al. End points and assessments in esthetic dental treatment. J Prosthodont Res (2015), http:// dx.doi.org/10.1016/j.jpor.2015.05.002
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4.
1.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Prosthodontics, also known as prosthetic dentistry, is the area of dentistry that focuses on restoration of partial and total edentulism and alveolar bone defects using biomaterials. Its focus is on improvement in oral function and esthetics. In prosthetic restoration of the anterior upper region, esthetic considerations (color and morphology of the teeth and gingivae and facial symmetry) are taken into account because of their influence upon the patient’s quality of life (QoL). Mori et al. [1] reported the results of a questionnaire given to 1457 workers at a major company, indicating that a smile and white teeth are very important to business relationships and that during communication, the gaze is drawn first to the eyes and then to the mouth. In a QoL questionnaire related to oral health (Oral Health Impact Profile [OHIP J-54], Japan Prosthodontic Society) [2], seven of the 54 items relate to esthetic factors; the questionnaire suggests that esthetic considerations of the mouth greatly affect patients’ QoL. General dentists are aware that esthetic dental treatment is a required skill. Esthetic restorations are not made of ceramic but are designed to create morphological and color harmony with the natural teeth, gingivae, lips, and face. In addition, restorations must maintain oral function and esthetics in the long term. Disciplines including prosthodontics, periodontology, oral surgery, orthodontics, and dental technology are involved in accomplishing the treatment goal. Because the esthetic conception is abstract, formulating a concrete treatment goal and communicating it between dentists and patients is difficult; carrying out esthetic treatments may also be difficult. The saying ‘‘dentistry is an art and science’’ is well known [3]. Science is a systematic action that organizes knowledge in the verifiable and logical form. Art is not just painting and drawing; it is the action of creating to fix various human activities and is not explained by theory and reason. Esthetic dentistry involves the field of art. Understandably, esthetic dentistry has no clear clinical guidelines. Even so, we must attempt to bring esthetic dentistry from the field of art to that of science to widely disseminate the knowledge and skill of esthetic dentistry and to enhance the treatment outcomes for general dentists. This article systematically describes the end points of esthetic treatments and assessments of esthetic outcome, which are important for acquiring skill in esthetic dental treatments.
2.
End point of esthetic dental treatment
Planning dental treatments in advance is indispensable in all clinical cases. Problems to be solved with dental treatment, including esthetics, should initially be determined through medical interviews and clinical examinations, and an end point or goal of treatment should be established. ‘‘Top-down treatment,’’ in which the treatment plan is focused on the
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desired end point, is a basic principle in prosthetic dentistry and should also be used in esthetic dental treatment. In this chapter, we discuss esthetic end points concerning the maxillary anterior teeth and facial profile.
2.1.
Esthetic harmony with existing teeth
With the maxillary anterior teeth, the end point of esthetic dental treatment is a restoration that is indistinguishable from the existing teeth and gums. If only a few teeth are missing or defective and the adjacent teeth have an appropriate form and color to use as a reference, the restoration should imitate them in form, color, surface texture, translucency, and characterization. Characteristics of the gums, such as the level of soft-tissue margin, soft-tissue contour, alveolar process, and soft-tissue color, should also be considered.
2.2.
Ideal esthetic criteria for maxillary anterior teeth
If all or most of the maxillary anterior teeth are missing or defective, determining the end point of esthetic dental treatments can be very complicated, but the possibilities of prosthetic design (tooth form, color, and arrangement) are greatly expanded. In these patients, the end point of esthetic treatment should be based on previously reported references for ideal esthetic anterior tooth conditions. Ideal esthetic criteria for the maxillary anterior teeth have been reported as follows (Table 1). The center of the dental arch matches the center of the facial surface, and the outlines of the teeth and gums are bilaterally symmetrical to the center of dentition [4]. The width to height ratio of the central incisor is ideally 1:0.75–0.8; this proportion is more important for esthetics than is the morphological relationship between the central and lateral incisors [5]. The ideal mesiolingual inclination of the central incisor is slightly distal, the laterals are inclined distally more than central incisors, and canines are more distally [6,7]. The lateral incisors is 1.0 to 1.5 mm above the level of the central incisors [8], and the incisal edge line of the anterior maxillary teeth approaches the lower lip line during a smile [9,10]. The ideal interproximal contact location of the central incisors is higher than the central-lateral or lateral-canine contact location. The interproximal contact of the anterior maxillary teeth should approach the lower lip line during a smile [6]. The ideal soft-tissue margin of the canines is higher than or the same as those of the central incisors, and the softtissue margin of the lateral incisors is lower than or the same as those of the central incisors [11]. The deepest position of the ideal soft-tissue contour is slightly distal to the center of the tooth [12] (Table 2).
2.3.
New SPA factors
In 1965, Frush and Fisher [13–15] proposed the concept of dentogenics, in which the selection and arrangement of artificial teeth and the festoon should be based on the sex,
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Table 1 – Ideal esthetic criteria for the maxillary anterior teeth.
Table 2 – Ideal interproximal contact location and softtissue form.
Esthetic factor
Esthetic factor
Esthetic criteria
The center of the dental arch The outlines of the teeth and gums The width to height ratio of the central incisor
To match the center of the facial surface Bilaterally symmetrical to the center of dentition 1:0.75–0.8
The mesiolingual inclination
The central incisor is slightly distal The lateral incisor is more distally than central incisor The canine is more distally than lateral incisor
The level of the anterior teeth
The lateral incisors is 1.0–1.5 mm above the central incisors The incisal edge line approaches the lower lip line during a smile
personality, and age (SPA factors) of the patient. They recommend a square shape for heavily-muscled men, a rounded shape for women, and teeth showing wear and deep color for elderly patients. Sex, personality, and age are often taken into consideration when designing removable dentures and are also applied to crowns and fixed partial denture prostheses. It is very important to satisfy each patient’s esthetic demands and to increase satisfaction with esthetic treatments. With the current social trend toward anti-aging treatments, patients increasingly request esthetically pleasing prostheses with a whiter color. Esthetic dental treatment is often expensive, and patients expect successful long-term results (prognosis). When results are poor, we fall into difficulties. A new definition of SPA factors needed for contemporary esthetic dental treatment may be satisfaction, prognosis, and anti-aging, rather than sex, personality, and age.
2.4.
Golden proportion
The golden proportion, in which everyone senses beauty and harmony instinctively, has been used as an esthetic guideline in both art and science. The golden proportion is the ratio between the length of a side of an equilateral pentagon to that pffiffiffi of its diagonal, which is 1:(1 þ 5)/2, or 1:1.618. The golden proportion has also been used in the practice of esthetic dentistry. For example, the dental anterior arch is considered most beautiful if the proportions of the maxillary lateral incisor width to central incisor width and of the maxillary canine width to lateral incisor width are equal to the golden proportion in the frontal side view [16] (Fig. 1). This proportion is based not on the anatomical width but on the frontal view.
2.5.
Esthetic balance of the facial profile
Esthetic dental treatments must take into account the balance of the facial profile as well as esthetic factors of prosthetics and gums. Matthews [6] reported that in a well-balanced facial profile, the distances between the hairline and the upper
Esthetic criteria
The interproximal contact location
The central incisors is higher than the central-lateral contact location The central-lateral incisors is higher than the lateral-canine contact location
The soft-tissue margin
The canines is higher than or the same as those of the central incisors The lateral incisors is lower than or the same as those of the central incisors
The deepest position of the ideal soft-tissue contour
Slightly distal to the center of the tooth
eyebrow margins, the upper eyebrow margins and the tip of the nose, and the tip of the nose and the chin (menton) are nearly identical. Ricketts [17,18] reported that the measurements between the external canthus, subnasale, angulus oris, and menton, which divide the face into three parts, are the golden proportions in an ideal face profile (Fig. 2). The overall facial profile cannot be altered solely by dental treatment; however, the vertical dimension, which affects much of the lower part of the facial profile, can be altered by dental treatment. The degree to which the maxillary anterior teeth are visible with the lips at rest must be considered when determining their form and position. The standard position of the incisal edge of the maxillary anterior teeth is approximately 2 to 4 mm below the bottom of the upper lip at rest [19,20]. However, it has also been reported that the position of the edge of the maxillary anterior teeth depends on age, sex, and lip tension and may range from 1 to 5 mm below the bottom of the upper lip [20,21]. Moreover, the mandibular anterior teeth become more exposed in elderly patients. Although the exposure of the anterior teeth differs widely among patients, the usual amount of exposure considering their sex and age must be taken into account [21]. The bottom line of the upper lip in the laughing position is referred to as the smile line. The positional relationship of the smile line and the maxillary anterior teeth influences the desired end point. Smile lines are classified into three types: low smile line, in which gingival embrasures and cementoenamel junction are not visible, ‘‘average smile line’’ in which only gingival embrasures are visible and ‘‘high smile line’’ in which gingival embrasures and cementoenamel junction are visible. Tjan et al. [10] reported that the ratio of low smile line was 20.5%, that of average smile line was 65.0% and that of high smile line was 10.5% and also reported that these ratio differed in each population, such as the races. In the case of high smile line in which gingival embrasures and cementoenamel junction visible, the esthetic dental treatment become to be more difficult because the patients demand improvement of gingival appearance as treatment outcome. Therefore, careful attention must be paid to the position of the smile line before the treatment.
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Fig. 1 – Width of maxillary anterior teeth and golden proportion. The ratio between the length of black line to that of white line is 1.618:1.
Fig. 2 – Balance of facial profile and golden proportion. The ratio between the length of black line to that of white line is 1.618:1.
profile, the upper and lower lips should both coincide with the E-line [24,25]. Results of a questionnaire of 150 people over 15 years of age also indicated that the upper and lower lips should be positioned approximately 1–4 mm posterior to the E-line [26], suggesting that Westernized facial profiles are becoming more popular in the Japanese population [27].
3.
Fig. 3 – Esthetic line.
It is well known that the ‘‘esthetic line’’, which shows the straight line connecting the Pogonion on the mucous membranes to tip of the nose [22], is used as to determine the esthetic end point for the lateral facial profile (Fig. 3). Reports indicate that in Japanese people, the upper lip coincides with the E-line and the lower lip is located outside the E-line [23]; however, for an esthetically pleasing facial
Assessments of esthetic dental treatment
The process of assessing treatment outcomes is essential for determining the success of esthetic dentistry treatment. Assessment consists of objective evaluation by the dentist and subjective evaluation by the patient. Objective evaluation is useful for assessing relative outcomes among patients; however, variations can exist between dentists. Subjective evaluation, on the other hand, is less useful for assessing relative outcomes but can be effective for assessing the absolute outcome. This section describes objective and subjective evaluations for assessing esthetic dental treatment.
3.1.
Objective evaluation
The White Esthetic Score (WES) [28] (Fig. 4) is used to objectively evaluate esthetic treatment outcomes of anterior single-tooth implants in the esthetic zone. The WES comprises tooth form, tooth volume/outline, color, surface texture, and translucency. A score of 2, 1, or 0 is assigned to all five
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Major Discrepancy Minor Discrepancy No Discrepancy
1: Tooth Form
0
1
2
2: Outline & Volume
0
1
2
3: Color (hue & value)
0
1
2
4: Surface Texture
0
1
2
5: Translucency & Characterizaon
0
1
2
Maximum Score: 10 Fig. 4 – White Esthetic Scores (WES).
1: Mesial papilla
0 Absent
1 Incomplete
2 Complete
2: Distal papilla
Absent
Incomplete
Complete
3: Level of so-ssue margin
>2 mm
1-2 mm
1< mm
4: So-ssue contour
Unnatural
Fairly natural
Natural
5: Alveolar process
Obvious
Slight
None
6: So-ssue color
Obvious difference
Moderate difference
No difference
7: So-ssue texture
Obvious difference
Moderate difference
No difference
Maximum Score: 14 Fig. 5 – Pink Esthetic Scores (PES).
elements by comparing to the other side tooth and assessed for complete agreement (score 2), incomplete agreement (score 1), or disagreement (score 0). The Pink Esthetic Score (PES) [29] (Fig. 5) specifically focuses on the following seven variables for gingival aspects of the implant site: mesial papilla, distal papilla, level of soft-tissue margin, soft-tissue contour, alveolar process, soft-tissue color, and soft-tissue texture. A score of 2, 1, or 0 is also assigned to all seven parameters. There is no evaluation item regarding the gingival biotype in this assessment. It will be because the gingival biotype affects the response of gingival treatment and the longevity of esthetic treatment, not the esthetic end point itself. Differences in the WES and PES among dentists may be caused by unclear assessment criteria or by too little grades. Fuhauser et al. reported that orthodontists were the most critical among twenty observers (five prosthodontists, five oral surgeons, five orthodontists, and five dental students) who assessed the PES of the soft tissue of 30 single-tooth implant crowns [29]. Cho et al. mentioned that periodontists were the most generous and prosthodontists were the most critical of eight observers (two periodontists, two prosthodontists, two orthodontists, and two dental students) who assessed the PES
and WES of 41 implant-supported single restorations [30]. Careful attention should be paid to the assessments of different observers, especially in different fields, when using the PES and WES.
3.2.
Subjective method
The OHIP [31] is a valuable subjective indicator of oral health. The Japanese version of the OHIP (OHIP-J), with 54 items, is derived from the OHIP [2]. For each OHIP-J item, participants are asked to rate the frequency of their experiences on a scale of 0 (never) to 4 (very often) for eight parameters: ‘‘functional limitation,’’ ‘‘physical pain,’’ ‘‘psychological discomfort,’’ ‘‘physical disability,’’ ‘‘psychological disability,’’ ‘‘social disability,’’ ‘‘handicap,’’ and ‘‘additional Japanese items.’’ The 54 items of OHIP-J include seven that estimate esthetics; however, the OHIP-J has no parameter specifically focusing on esthetics. Therefore, the OHIP-J has little validity for assessing the direct outcome of esthetic dental treatments. The visual analog scale (VAS) [32] is another valid and reliable instrument for measuring subjective outcomes. Many studies have reported the subjective outcome of ‘‘patient acute pain’’ as measured by the VAS. Patients are asked to
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Dental Self-Confidence I am proud of my teeth. I like to show my teeth when I smile. I am pleased when I see my teeth in the mirror. My teeth are aracve to others. I am sasfied with the appearance of my teeth. I find my tooth posion to be very nice.
Social Impact I hold myself back when I smile so my teeth don’t show so much. If I don’t know people well, I am somemes concerned what they might think about my teeth. I’m afraid other people could make offensive remarks about my teeth. I am somewhat inhibited in social contacts because of my teeth. I somemes catch myself holding my hand in front of my mouth to hide my teeth. Somemes I think people are staring at my teeth.
Remarks about my teeth irritate me even when they are meant jokingly. I somemes worry about what members of the opposite sex think about my teeth.
Psychological Impact I envy the nice teeth of other people. I am somewhat distressed when I see other people’s teeth. Somemes I am somewhat unhappy about the appearance of my teeth. I think most people I know have nicer teeth than I do. I feel bad when I think about what my teeth look like. I wish my teeth looked beer.
Aesthec Concern I don’t like to see my teeth in the mirror. I don’t like to see my teeth in photographs. I don’t like to see my teeth when I look at a video of myself.
Fig. 6 – Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ).
mark their pain intensity on a 10-cm ruler. A mark at 0 cm (a VAS value of 0) signifies ‘‘no pain at all’’; a mark at 10 cm (a VAS value of 100) signifies ‘‘the worst pain possible.’’ The VAS scale has been applied to outcomes of esthetic dental treatment as well as to pain. Some studies have used the VAS to report esthetic outcomes including teeth alignment, color, and morphology of the teeth and the shape of the gingivae. In these cases, 0 cm on the scale signifies ‘‘not satisfied at all’’ and 10 cm signifies ‘‘very satisfied.’’ The VAS scale has high reliability and reproducibility [5,33–36]; however, it requires careful attention to take each question a different way among patients. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), reported by Ulrich Klages et al. [37], supplies very valuable information concerning esthetics after orthodontic treatment (Fig. 6). The PIDAQ contains 23 items and four subscales that represent esthetic concerns in three items, psychological impact in six items, social impact in eight items, and dental self-confidence in six items. For each item, participants are asked to respond with scores of 0 (not at all), 1 (a little), 2 (somewhat), 3 (strongly), or 4 (very strongly). If the patient has high satisfaction with esthetics, the PIDAQ score for dental self-confidence will be high, and the scores for the other subscales will be low. Few studies concerning the outcome of esthetic dental treatments using the PIDAQ have been reported [38]. However, the PIDAQ has recently been translated into other languages [39–42], so it may become effective for evaluating the esthetic outcome not only of orthodontic treatment but also of prosthodontic treatment.
4.
Conclusion
There are two key considerations for successful esthetic dental treatments. One is that esthetics is a value judgment
that is not universal and depends on various factors such as age, race, and district of residence. It may be difficult to understand a patient’s goals for esthetic dental treatment. The best way to reach the treatment goal is to understand the end points that we have proposed in this article and reach an agreement with the patient through a medical interview. The other consideration is that the end point and treatment plan is greatly influenced by each patient’s wishes and financial resources and the dental team’s treatment skills and environment. We believe that treatment skills are improved through the PDCA (Plan-Do-Check-Act) cycle. Appropriate assessments in the PDCA cycle are required to improve treatment skills. Although we have discussed some subjective and objective assessments in this article, there is no gold standard for esthetic assessment. Practitioners should understand the characteristics of each assessment tool and use the one most appropriate for each situation. Continuing improvements and developments of esthetic assessments are required to raise the therapeutic level of esthetic dental treatments.
Conflict of interest No potential conflicts of interest were disclosed.
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