All FULL FACE Before and After Photographs
Goals of Treatment
Many years ago I invented a term called "Perception Esthetics" which is a term that highlights the importance of perception in creating smiles. It is a philosophy which expresses an understanding that various smile designs are used to produce natural smiles. A dentist's perception of a patient results in a final smile design to fit that person.
Appreciation of esthetic dentistry as an art form varies. Defining patient esthetic values and level of appreciation is essential to achieve patient satisfaction. If proper assessment of a patient is not accomplished, final smile design is the artistic interpretation of a dentist that may or may not be acceptable to a patient.
A dentist who does not understand perception esthetics produces the same smile for every patient limited only by physical or financial limitations. The perfect smile of the "Golden Rule" can be ideal for a young patient of twenty years old but not for a patient of seventy years old. A smile of seventy years would incurred defects such as tooth rotation, wear, color change, arch collapse, or the like. An ideal smile which is perfect for a twenty year old is too perfect and not normal for a person of seventy.
INFLUENCES ON SMILE DESIGN WITHIN PERCEPTION ESTHETICS
Treatment goals must be balanced within limitations of ideals and limitations of treatment. Limitations of ideals are subdivided into general traits (cultural, physical and personality limitations), detailed inspection and visual perception. Limitations of treatment are subdivided into patient and dentist limitations. Patient limitations include physical, psychological and financial limitations.
Dentist limitations include artistic, perceptive and technical ability to include material and laboratory limitations.
The case above shows diastema closure between the maxillary incisors. The lateral incisors have the incisal added to for increased tooth length.
PATIENT LIMITATIONS
LIMITATION OF IDEALS.
Perception esthetics considers the psychological and philosophical components of esthetic dentistry from a dentist and patient point of view. When a dentist analyzes a patient to judge perception of personal characteristics, matching perceived physical, cultural and psychological characteristics to preconceived perceptions results in interpretation of normal smiles for individuals. Preconceived perceptions result from observing smiles of similar individuals. For example, observing eighty year old persons describes what is normal for an eighty year old patient.
The ideal smile is the best smile ever seen for an individual with the same esthetic influences. In fact, often the very best may be too good and expectations should be lowered to form harmony with all esthetic influences.
Esthetic goals are improved if it is anticipated perception esthetic influencing factors are going to be improved. In reality, we often see other esthetic influencing factors such as hair, make up, etc. improve after esthetic dentistry is completed. Limitation of ideals has three major avenues of discovery including: 1. general perception, 2. detailed inspection and 3. visual perception. These factors can be very subtle or dominating.
1. GENERAL PERCEPTION
Preconceived factors based on our experiences of viewing smiles influence our concepts of what a person's teeth and smile should look like. Preconceived factors include physical, cultural and personality characteristics. Preconceived ideals defines our goals for treatment while simultaneously considering that preconceived ideals of a patient may differ from a dentist.
PHYSICAL CHARACTERISTICS
Physical characteristics of a person are initially viewed as a general appearance as if viewed from a distance. Preconceived perception and our perception of what someone's teeth should look like is based on factors such as age, clothing, hair, cleanliness, make up, skin, stature, height, weight, age and mannerisms. We expect to see the beautiful teeth of the "Golden Rule" on a professional model, but a husky, coal mine worker would have tough teeth with worn, flat, chipped incisal edges and no incisal embrasures or even a missing tooth.
CULTURAL CHARACTERISTICS
Cultural
characteristics are based on the environment surrounding an individual. We
expect to see more defects on people living within a coal mining community in
Cultural characteristics, and therefore, cultural preconceived perceptions, can be defined as large or small generalizations based on racial characteristics, country, city, community, neighborhood to as small as household characteristics. Cultural esthetic values of people are defined by factors such as attitudes of a community, economic limitations, dental IQ, and general esthetic values. Influences on smile design based on culture can be subtle or dominating depending on the individual and culture.
Dental esthetic evaluations are difficult because they are done in the dental office which may be different than the patient's normal environment. This makes a dentist's evaluation and subsequently patient acceptance difficult. If a patient who was a nomad from central Africa
The great equalizer, which can minimize cultural preconceived concepts, are smiles viewed through media such as television, magazines, and the like. Indeed, this is probably a subculture of its own which has broad influence.
PSYCHOLOGICAL PERCEPTIONS
Psychological perceptions occur prior to, and personality traits realized after meeting an individual. Information received prior to meeting someone may include a description of physical attributes, education, profession, environment, or emotional make up of an individual. Frequently, we hear descriptions of individuals and are surprised how different in person the individual really is from our expectations. Expectations of smiles are similar.
Personality traits realized when meeting an individual can include happy and cheerful, stressful and obnoxious, or the like. Each personality trait will influence our expectations of what teeth do or should look like based on individuals we know with those traits.
2. DETAILED INSPECTION
Detailed inspection of physical characteristics begins with examination of the head. Observation of outline form of the face and head occurs initially to be followed by slowly focusing to details within the mouth. Size and shape of the face and head can include large, small, long, broad, square, tapered, ovoid, or the like. Observation of general orthodontic classification such as I, II, and III or long and short face syndromes defines a perception of arch shape, arch size and arch to arch relationships. Face and head outline form can be profoundly influenced by hair shape and color variation. Evaluation of the lips will give further hints to arch size, arch shape, arch to arch relationships and tooth position though lips can also hide information.
Perception and reality blend when teeth and arches are seen as the lips retract during function and ultimately with a smile. General influences like midline, incisal edges, lower vs. upper teeth, color/discoloration, and symmetry will be followed by detailed influences such as individual incisal edges, silhouettes/embrasures/line angles and tooth shape and color.
3. VISUAL PERCEPTION
The perception of a smile is formed by a series of frameworks including gingiva, lips, cheeks, face and hair. A smile should be considered as teeth surrounded by head structures such as lips, cheeks, nose, eyes, ears, face shape and hair which ultimately, is surrounded by a personality. The action, interaction and overall perception of individual and overall features results in our perception of a smile. Perception of size and color of teeth is relative to surrounding frameworks and structures.
Restorative dentists influence a smile by changing teeth within the influences of these frameworks. Frameworks and facial features may be changed by referral to a specialist within the medical or dental professions. The results of esthetic treatment must be evaluated within the realm of general physical, cultural and psychological characteristics of an individual.
LIMITATIONS OF TREATMENT
The limitations of treatment are classified into two major categories including patient limitations and dentist limitations. Patient limitations include financial, psychological and physical conditions. Dentist limitations include artistic, perceptive and technical limitations along with material and laboratory limitations.
1. PATIENT LIMITATIONS
A. FINANCIAL LIMITATIONS
Financial limitations restrict what treatment can be performed by defining the number of, the type of and the time within which procedures can be accomplished. An example is a patient who cannot afford to have porcelain veneers so direct composite veneers are done because this is an affordable option
B. PSYCHOLOGICAL LIMITATIONS
Patient psychological limitations, which include esthetic perception and preconceived esthetic perception limitations, are the most challenging factors to decipher but are the most significant to determine.
LEVEL OF PERCEPTION/ARTISTIC ABILITY
Patient esthetic perception is the level of recognition of details within treatment results. There are different levels of perception various individuals have so consequently some patients are easy or hard to satisfy. For example, one patient does not notice a brown spot on a central incisor while another patient notices a brown stain in a central pit of a second molar. In addition, patients have different levels of artistic ability to analyze color, shape and smile design. Often fillings are done which are an incorrect color or shape and a patient finds the result acceptable. Difficulty arises when esthetic perception, artistic ability and goals are unattainable or not realistic for individual esthetic perception characteristics.
PATIENT GOALS
Patient preconceived esthetic perception defines a patient's image of what the final result of their esthetic treatment should look like. The image normally reflects the images a patient has experienced (as described within limitations to ideals in this article). The patient goals further reflects a patient's image of themselves or an image they wish to convey.
Dentists must analyze patient preconceived esthetic perceptions and level of esthetic perception before treatment begins. Education must follow to attempt to make expectations realistic and ultimately accomplish patient satisfaction when necessary.
Consider the following treatment goals where patient goals dictated results. The goal of this patient was to have teeth as white "as the dentist's laboratory coat". Education through photography and modified temporaries could not convince the patient that the results of perioprosthetic crown and bridge splint treatment should be a natural color. The result was a smile with teeth too white for her perception esthetic characteristics. The patient, however, was satisfied with the results.
C. PHYSICAL LIMITATIONS
Physical limitations can easily be defined through proper diagnosis and treatment planning. The most common limitations are gingival, arch size, shape, and position relative to each other and arch position relative to the head, lips and teeth. Teeth in relation to each other including, cross bite, end to end and overbite/overjet can provide further limitation. Often, physical limitations occur if a patient is psychologically unwilling or financial restrained from doing procedures such as orthodontics, periodontic or orthognathic surgery. These are considered financial or psychological limitations of physical limitations.
Consider the results of treatment of a patient with physical limitations of cross bite, arch shape and arch position. The patient was unwilling to undergo orthodontic treatment. Proper diagnosis and treatment planning allowed acceptable treatment with a maxillary fixed bridge and crowns, mandibular cuspid and posterior crowns and esthetic recontouring of the mandibular incisors along with proper mandibular repositioning. Slanting gingival contours are hidden by the lip framework. The result is an improved smile acceptable to the patient.
Limitations which are easily changed by a restorative dentist include changes to minor tooth position, size and color. In addition, perception of individual tooth size is altered by proper use of line angles, embrasures forms, contacts, incisal edges, surface contours, long axis alteration and color.
PERCEPTION ESTHETIC TREATMENT
It is important to define an ultimate smile design as occurs with the smile of the "Golden Rule" so differences can be defined by comparison. Alterations or imperfections to an ideal smile can include changes to 1. tooth color to include: discoloration, decalcification, stains, craze lines, fillings or cavities, and 2. tooth position to include: tipping, rotation, crowding, eruption, root exposure, diastemas or tooth loss, and 3. tooth shape to include: cracks, chips, cavities, wear, abrasion, attrition, abfraction, surface defects, surface contours and surface texture.
A dentist must define when procedures and materials are ideally used so changes as are required with perception esthetics can be identified. For example, generalizations can include: esthetic recontouring to be used when alterations are confined to enamel and the resulting teeth are dimensionally correct; composite to be used for small surface defects, diastema closure, small carious lesions and minor changes in tooth position; porcelain veneers to be used for major changes in tooth color, position and shape and when increased appearance and strength is desired; and crowns to be used when tooth structure is not strong enough to support bonded porcelain.
Maximizing treatment results utilizing perception esthetics requires understanding of limitations of ideals and limitations of treatment. It is knowing normal smiles which allows an artist to recreate them. It is knowledge about a patient and experience which allows a dentist to know how to create a natural smile
Photography
is perhaps the best ally in studying perception esthetics. For example,
photographing farmers in
Photography of treatment results and of natural teeth also provides an educational base for patient perception/psychological evaluation and education. Defining tooth defects of position, shape and color, showing them to a patient and identifying what is acceptable, allows predictable utilization in smile design.
DENTIST LIMITATIONS
Finally, a dentist must recognize the limitations of dental materials, the dentist's ability to perform esthetic dentistry and to maximize perception with shape and color, the dentist's artistic ability and the ability of a laboratory to recognize and communicate perception esthetic dentistry. Difficulty arises when a patient's level of perception and artistic ability is greater than a dentist's.
A dental laboratory has control of esthetic results when services are required. A laboratory technician is limited by materials, technical ability, artistic ability, level of perception and limitations placed by a dentist.
Consider the results of treatment using perception esthetics in a case in which dentist and laboratory technical ability is critical. Size of teeth would appear large if proper use of tooth position, shape and color were not used in creating a new smile with porcelain veneers/ bonded porcelain. A technician must understand proper utilization of line angles, embrasures, contacts, surface contours, surface defects, incisal edge variation/length, and color variation to make large teeth have a perception of being smaller.
In summary, perception esthetics provides a philosophy to produce maximum and yet realistic treatment results and patient satisfaction. While influences can be subtle, they are real factors which should be considered when evaluating and performing esthetic treatment to achieve patient satisfaction.
COLOR POSITION SHAPE
discoloration tipping chips
craze lines rotation cracks
decalcification crowding gingival to face
fillings tooth loss abrasion
stains eruption cavities
dentin exposure diastema wear
cavities intrusion surface defects
Copyright Cosmetic Dentist Wellesley
Paul R. Chalifoux, DDS
277 Linden Street Suite 209
Wellesley, MA 02482
781-235-1747
chalifoux@comcast.net