Canted Smile Line treated with Porcelain Veneers

This canted smile was corrected with a surgical nivellation
of the gum line and porcelain veneers.

The aesthetic assessment of a smile depends on many dental, oral, and facial parameters and their ability to harmonize as a whole. Throughout this discussion, cosmetic dentist of San Francisco, Dr. Jorg-Peter Rabanus, DDS, explores specific shortcomings of the aesthetic zone of the dental arch and how porcelain veneers can correct them. One particularly rare and challenging condition is a canted smile line combined with a canted dental midline. These imperfections, as illustrated in the accompanying images, often disrupt the balance and harmony of a smile.

Understanding Smile Aesthetics

A harmonious smile is often defined by the alignment and symmetry of its elements. Ideally, the incisal edge of the upper teeth should follow the inner border of the lower lip, and the incisal plane should remain perpendicular to the dental midline. Symmetry, a key parameter in human anatomy, plays a critical role in aesthetic appeal. The human eye is particularly sensitive to even minor asymmetries in line angles, especially on the face. While no face is perfectly symmetrical, there is a threshold beyond which asymmetry becomes noticeable and detracts from facial harmony. Examples of such disruptions include facial asymmetries observed in stroke victims, imbalanced muscle tone after poorly administered Botox injections, or facial paralysis caused by trauma or local anesthesia.

When the smile line and midline are canted, the overall appraisal of the smile is affected. The observer’s attention is drawn to the disharmony rather than to the smile’s intended expression. However, once dento-facial harmony is established, the entire perception of the smile changes. It becomes softer, more appealing, and capable of conveying the subtle nuances that define human emotion.

The Path to Harmonious Smiles

Achieving such results requires meticulous planning and execution. It begins with a comprehensive analysis of dental models and a diagnostic wax-up of all teeth involved. This initial step is critical for understanding how the teeth relate to one another and the broader facial structures. The diagnostic wax-up serves as a template for mock-up surgeries, which are performed on dental models. These models guide the periodontist in executing a crown-lengthening procedure that is aimed at leveling the smile line.

The diagnostic wax-up is designed to anticipate the surgical outcomes and is transferred into provisional acrylic restorations. This transfer process involves creating negative imprints of the wax-up, which are subsequently filled with tooth-colored, self-setting acrylic. These provisional restorations are then placed on the prepared teeth in the patient’s mouth, allowing the patient to experience their new smile and provide feedback on the design. During this stage, the dentist conducts thorough follow-up visits to ensure that the newly designed teeth align functionally and aesthetically with all oral and facial structures, across various functions.

The provisional restorations are an essential tool for achieving patient satisfaction. They allow for consecutive adjustments based on the patient’s feedback and functional requirements. Once the patient approves the provisional restorations as an aesthetically and functionally cohesive unit, the cosmetic dentist collaborates with the dental laboratory to fabricate the final porcelain veneers.

Refining Aesthetic Elements

With the fundamental structure of the new teeth established, the focus shifts to refining aesthetic details. Key considerations include:

• Incisal Translucency: The degree of translucency at the tips of the teeth is carefully adjusted to mimic the natural appearance of enamel.
• Shade and Color Composition: Variations in shades and colors are introduced to create a lifelike effect.
• Micro-Elements: Details such as incisal embrasures, notches, and the overall tooth contour are fine-tuned to enhance realism.
• Proportions: Elements like central dominance and adherence to the Golden Proportions are analyzed to ensure a balanced smile design.

These refinements are carried out in close collaboration with the patient, ensuring that their preferences and expectations are fully incorporated. Dr. Rabanus emphasizes the importance of patient involvement, adhering to the principle that “you don’t have to be a dentist to make an educated choice.” This philosophy ensures that patients are well-informed and confident in their decisions about the aesthetic elements of their new smile.

Comprehensive Approach to Smile Design

The transformation process does not solely focus on aesthetics; functional harmony is equally critical. Each adjustment is made with an understanding of how the teeth interact with one another and the surrounding oral structures. This comprehensive approach ensures that the final result is not only beautiful but also durable and comfortable for the patient.

The diagnostic phase is a cornerstone of this process. By creating a detailed wax-up and using it as a blueprint for both provisional restorations and surgical procedures, the cosmetic dentist lays a strong foundation for success. This phase also involves advanced imaging and 3D modeling technologies, which enhance the accuracy of planning and execution.

Patient communication is another vital aspect of smile design. From the initial consultation to the final placement of veneers, the dentist must ensure that the patient’s concerns, preferences, and expectations are fully addressed. This collaborative process fosters trust and results in a smile that the patient is proud to showcase.

Achieving Dento-Facial Harmony

The case presented here illustrates the transformative power of dento-facial harmony. Before treatment, the canted smile line and midline drew attention away from the patient’s natural expressions. After treatment, the smile became a cohesive and attractive feature, enhancing the patient’s overall appearance and confidence.

This transformation highlights the importance of symmetry and alignment in smile aesthetics. By aligning the incisal edge with the lower lip and ensuring that the dental midline is perpendicular to the incisal plane, the cosmetic dentist creates a balanced and harmonious smile. These adjustments, though subtle, have a profound impact on the overall perception of facial aesthetics.

The Art and Science of Porcelain Veneers

Porcelain veneers are a cornerstone of modern cosmetic dentistry. They offer a versatile solution for a wide range of aesthetic concerns, from discoloration and misalignment to asymmetry and worn teeth. The success of porcelain veneers lies in their ability to mimic the natural structure and appearance of teeth while offering superior durability and stain resistance.

The process of designing and fabricating porcelain veneers involves a blend of art and science. Dentists must have a deep understanding of dental anatomy, materials science, and aesthetic principles. At the same time, they must possess the artistic skill to create veneers that blend seamlessly with the patient’s natural teeth.

A Patient-Centric Approach

Dr. Rabanus’ approach to cosmetic dentistry places the patient at the center of the process. By empowering patients with knowledge and involving them in every step of the design process, he ensures that the final result aligns with their vision and expectations. This patient-centric philosophy extends beyond aesthetics to include considerations of comfort, functionality, and long-term oral health.

The journey to a new smile is transformative, not only in terms of appearance but also in terms of confidence and self-esteem. Patients often report feeling more self-assured and willing to engage socially after undergoing smile makeovers. This psychological impact underscores the value of cosmetic dentistry as a tool for improving quality of life.

Conclusion

The aesthetic assessment of a smile is a complex interplay of dental, oral, and facial parameters. Conditions such as canted smile lines and midlines present unique challenges but can be effectively addressed through meticulous planning, advanced techniques, and patient collaboration. By combining functional harmony with aesthetic excellence, cosmetic dentists create smiles that are not only beautiful but also natural and enduring. Through the use of diagnostic wax-ups, provisional restorations, and detailed refinements, the art of smile design achieves its ultimate goal: enhancing the patient’s natural beauty and confidence.

References:

Claude R Rufenacht. Fundamentals of Esthetics. Chicago, IL: Quintessence Publishing; 1990.

Claude R Rufenacht. Principles of Esthetic Integration. Chicago, IL: Quintessence Publishing; 2000.

Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago, IL: Quintessence Publishing; 1994.

Morley J. The role of cosmetic dentistry in restoring a youthful appearance. J Am Dent Assoc. 1999;130:1166-1172.

Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.

Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics: asymmetric and symmetric situations. Am J Orthod Dentofacial Orthop. 2006;130:141-151.

Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.

Carruthers J, Carruthers A. BOTOX use in the mid and lower face and neck. Semin Cutan Med Surg. 2001;20:85-92.