Creating the Perfect Smile – Part 1

17 May
Creating the Perfect Smile

Smile Design is NOT Simple

In this 5-part article, I will describe the details and the challenges of smile design in cosmetic dentistry, as well as the key reasons why things can go wrong.

Cosmetic dentistry is not as simple as “slapping on” some porcelain and changing the patient’s life. Many factors, details, and principles must be understood and applied when evaluating and providing smile makeovers. One of the most important aspects to consider before any treatment begins is the patient’s desired final results and their expectations of how this is to be achieved. I like to break this down into 3 categories: (1) The essentials, (2) The tools, and (3) The unexpected.

(1) The Essentials

Complete information and documentation is a must to achieve a proper diagnosis. This includes the patient’s medical and dental history, a comprehensive dental exam, evaluation of the muscles and temporo-mandibular joint (TMJ), and proper and complete radiographs. Every now and then we get patients that refuse some or all X-rays and when it comes to elective procedures like cosmetic dentistry, this becomes even more important. There are many issues, pathological conditions, and aspects that can impact and influence the final results and, in cosmetic treatment planning, this is where having all diagnostic information is critical to a good outcome.

(2) The Tools

Photos of the patient are key to the planning process as well as a way to uncover possible skeletal deficiencies which could impact the final results. An evaluation of the patient’s overall features, including facial proportions and esthetics in vertical and horizontal planes can uncover asymmetries which are often an indication of skeletal or growth and developmental issues that may or may not have an impact on the patient’s smile. A gummy smile, for example, could be due to an excessively long middle third of the face indicating vertical maxillary excess, which is a skeletal issue and requires a different treatment modality to successfully treat the patient’s concerns.

When it comes to visualizing possibilities and challenges in smile design, photos of the patient’s smile from various angles, and positions will bring a lot of key insights into proper treatment planning. Posture and side views of the patient are also very important as they can shed light on possible jaw alignment problems, temporo-mandibular dysfunction (TMD) and muscle-related conditions that could have negative consequences if not recognized. In addition, retracted views of teeth taken at various angles offer an important perspective to allow for consideration of challenging tooth alignment or position that can easily be missed during a simple examination. Finally, mounted models of the patient’s teeth are viewed on a dental articulator in order for the clinician to be able to fully assess all aspects of occlusion, including the Curve of Spee and Curve of Wilson, which are both critical in proper chew function.

(3) The Unexpected

This is the category where most dentists get into trouble, and most failures occur. What makes cosmetic dentistry most problematic is lack of understanding of the patient’s expectations of the final results and their impact on the patient’s life. Assuming the clinician is skilled and trained in the details and intricacies of smile design, clinical steps, materials, and maintaining occlusion, defining the goals and potential challenges that the patient brings is critical to a happy outcome. In my years of practice, I have treated patients with all kinds of expectations and assumptions ranging from typical and obvious like cost, discomfort, or time, to the wildest and most unusual. The obvious ones aside, knowing what the patient’s expectations are before any treatment begins helps the clinician not only manage the process of delivering the best outcome, but also know when to say no. Sometimes we simply cannot deliver what the patient wants. In simple terms, I can’t give someone super long teeth if their occlusion, facial features, and general smile guidelines don’t allow. I also can’t do it in a quick short visit, no matter how fast I prep. But asking some key questions, defining the steps of the procedure, what it will feel like, how we will manage if we have to make changes, and what the limitations are when it comes to the actual esthetics is only the beginning of this discussion. Some patients are easier to work on than others; some require frequent breaks or can’t be reclined for a lengthy period of time. Others have medical conditions or dental issues which will impact how and when we can treat them. But the psychology of the patient, how detail-oriented they are, and how they define “The perfect smile” is where I would spend the most time on. I once had a patient that fully and completely believed that she would find her soulmate if she fixed her smile. After her smile makeover, when her love life didn’t change, she was angry and enraged that she wasn’t given a full refund for the money she spent on her new teeth! Knowing what your patients expect to happen as a result of their makeover may be an important question to ask.

There are many critical factors to consider in smile design and creating a perfect smile requires that the clinician understands and applies these in the planning stages of their patient’s new smile. See Part 3 to learn about these as well as how to manage all aspects of design when delivering cosmetic dentistry.

See Part 2 to continue

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