Uia Estetica

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Jean-Christophe Paris, DMD

Private practice, Aix en Provence, France
Stphanie Ortet, DMD

Private practice, Aix en Provence, France
Annick Larmy, DMD

Private practice, Marseille, France
Jean-Louis Brouillet, DMD, DDS

Andr-Jean Faucher,DMD,DDS
Correspondence to: Dr Jean-Christophe Paris

Academie du Sourire, 12, Cours Sextius, Aix en Provence 13100 France
Tel: 00 336 11226371; e-mail: jcp@academie-du-sourire.com
50
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 NUMBER 1 SPRING 2011
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for Success in a Complex Case
Smile Esthetics: a Methodology
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CLINICAL APPLICATION
Abstract
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The clinical case presented is the dem-
ing of the smile. This type of multidisci-
onstration
ap-
plinary treatment, which seems compli-
proach to a complex treatment. A pre-
cated at rst, is greatly simplied once
cise methodology is important to ensure
time has been spent on the diagnosis
that the treatment objectives are clear
and treatment plan: it thereby becomes
to all the teams. The aim of the treat-
a succession of clinical stages.
of
multidisciplinary
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showing severe attrition of the anterior
ss e n c e
teeth. The direct effect of this is an age-
ment is to restore dentofacial harmony

to a young, 22-year-old, female patient
(Eur J Esthet Dent 2011;6:5074)
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Materials and methods
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a weapon of seduction, the primary
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The smile can be a snapshot of the soul,
Introduction
The Decision-Making Table
means of communication, a reection of
By referring to the Decision-Making Ta-
personality so many denitions, which
ble3, it is possible to analyze a smile in
underline the essential role of the smile
its entirety and approach a case study in
in expression and communication be-
a precise and methodical way.
tween human beings.
Using the guiding principles, which
The direct relationship between the
govern smile esthetics, the Decision-
beauty of the smile and self-esteem
Making Table (Fig 1) is a therapeutic tool
should also be mentioned, an extremely
that allows the clinician to reinforce an
important notion regarding the quality of
esthetic diagnosis and treatment plan.5
ones socio-professional life.1-3
Indeed, this evaluation of esthetic crite-
These reections afrm that the es-
ria is more than just an analysis of the
thetic restoration of the patients smile
dental composition. It also includes the
is an essential medical act. It can never
gingival tissues and the nal esthetic
be approached with anything less than
restoration in the framework of the smile
a perfectly codied method, which rules
and face, taking into account the pa-
out failure, even if the success is not
tients personality.
complete.
Thus, during an esthetic consultation,
This method consists of a checklist,
this guide quickly brings to light any lo-
which brings together all esthetic and
calized problems which will be treated
functional parameters. It claries and
and assimilated into an initially-harmo-
facilitates the work of clinicians, so that
nious smile, or determines if there is a
they are able to perform complex es-
global problem, which then requires re-
thetic rehabilitation by following clear,
habilitation of the smile.3
step-by-step guidelines. A number of

checklists have been described in the
This new diagnostic approach will be

illustrated in the following clinical case.
dental literature, and one of the most accomplished is that of Mauro Fradeani in
The Esthetic Guide (EG)
2004.4
The clinical case described hereaf-
When confronted with complex smile re-
ter reects this approach and method
habilitation, it is essential to think about
of diagnosis, which has been called the
and elaborate a structured case study.
Esthetic Guide.
This is why, during the clinical exam,
The rst step was to a make a deci-
the use of the Esthetic Guide (Fig 2) al-
sion regarding the treatment, either par-
lows for the collection of a great deal of
tial, by integrating into an existing smile,
information relating to the patient (face,
or global, by bringing a new harmony to
smile, occlusion, and dental and gingi-
the smile.
val composition).6
The Decision-Making Table facilitates

this decision.
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The Esthetic Guide is a guide to a clinicians therapeutic and esthetic decision,
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Balanced smile
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Disharmonious smile
Decision-Making Table
I. Face
U localized problem
U global problem
U
I.1 Visual balance

between look and smile
II.1 Smile line
U too high
U too low
U irregular
U too high
II. Smile
II.2 Esthetic frontal plane
U too low
U asymmetrical
II.3 Sagittal plane
II.4 Horizontal plane
III.1 Dimensions
III.2 Proportions
III.3 Shade
III.4 Shapes
IV.1 Gingival architecture
U Integration
U Rehabilitation
III. Dental composition
IV. Gingival composition
Fig 1
Decision-Making Table.
depending on the results of the patient

examination.
Radiographic status
The radiographs did not show any endodontic or periodontal conditions.
Photographic status
In esthetics, this collection of perfectly
codied documents is fundamental to
Fig 2
The Esthetic Guide.
the establishment of the treatment plan,

in the same way as radiographs are for
the endodontist (Figs 3-14).
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Frontal view.
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Fig 3
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Fig 4
Fig 5
Full smile.
Fig 6
Four-tooth smile.
Fig 7
Right view.
Fig 8
Left view.
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Side view.
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Fig 9
Frontal view (rest position).
Fig 10
Frontal view (edge-to-edge bite ).
Fig 11
Right view (canine edge-to-edge).
Fig 12
Left view (canine edge-to-edge).
Fig 13
Maxillary occlusal view (mirror).
Fig 14
Mandibular occlusal view (mirror).
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Fig 15 (a to c)
The examination of the study
models shows a number of functional anomalies:

indeed, the abrasion of the anterior teeth reveals a
parafunction of the bruxism kind and dysfunctional
c
lateral movements.
Indeed, they enable the collection of
Clinical case
all the information regarding the initial situation, and constitute an element of ob-
A 22-year-old woman arrived at the of-
jective comparison following treatment.
ce, showing severe esthetic problems.
They are also a tremendous means of
Her smile, which she was embarrassed
communication with the patient and the
about, revealed abraded and highly-dis-
ceramist, giving precise indications.
colored teeth. The medical questionnaire

indicated that during her adolescence,
Analysis of study models
she had two serious orthodontic treatments in order to put the two impacted
Study models constitute a three-dimen-
maxillary canines into their correct place.
sional reference of the initial situation
Being perfectly aware of the impact of
(Fig 15). Set in an articulator, they fa-
this kind of imbalance on her personal-
cilitate the dynamic appraisal of patient
ity, this young patient shared her wish to
function and make potential problems
nd once again a smile in harmony with
visible.
her age.
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fo r
Fig 16
Decision-Making Table of the patient.
Fig 17
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This frontal view of the face demonstrates
a signicant contrast between this discreet smile

and the dominant look of the teeth, which the patient
is trying to hide.
The patients esthetic expectations
Esthetic analysis
Taking into account this patients es-
Details of the Decision-Making Table for
thetic
the present case (Fig 16) follow.
requests
was
fundamental
step in the clinical success of her

smile.5 Being attentive to patients and
Study of the face
respecting their wishes enables per-
A balance between the intensity of the
sonalized treatments, while remaining
look and the vitality of the smile is es-
within the functional possibilities and
sential to the harmony of the face. It is
morphophysiological characteristics of
therefore the primary parameter to be
the patient.6-8
determined (Fig 17).
Indeed, a standardized esthetic approach is simply not possible. It is not
Study of the smile
just an impersonal analysis of criteria.
The smile line is probably the most im-
Each patient and each smile is unique,
portant feature of the smile. It is the posi-
and the practitioner needs to know how
tion of the teeth in relation to the soft tis-
to create a natural harmony in order
sue: lips and gums. The smile line can be
for the beauty to be born again.3 In this
low, medium, or high.9 In this case, the
particular case, the patient provided
smile line is low, the patient reveals only
photographs illustrating the smile she
a little of her teeth (Fig 18a). Because of
desired.
excessive abrasion of her incisors, the

esthetic frontal plane is at and does not
correspond to the patients real age.
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Fig 18 (a to d)
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The shape of the teeth did not correlate with the patients face, personality, or age.
The maxillary anterior teeth seem to

be too buccal in comparison with the
the canines are not sufciently

present in the smile (Fig 18b).
maxillary lip. The presence of signicant

diastema
makes
unsightly
so-called
black holes visible (d13-14 = 1 mm,
The excessively dark color of the teeth

contributes to a recessive smile.
d23-24 = 3 mm) (Fig 18b).

Study of the gingival composition
Study of the dental composition
The dental composition is highlighted
Measuring the teeth allows the clinician
by the harmony of the gums, which
to appreciate their proportions within the
through their healthy state and harmo-
smile.
nious architecture reinforce the unity of
Studying the width/length ratios7,10
the smile.4,6 It is therefore an element
enables one to reach the following con-
that should be taken into careful consid-
clusions:
eration. A signicant gingival recession
the incisors are too short (Fig 18c)
was located at the maxillary left canine;
the central incisors are too narrow
when probing, the visibility of the probe
and square
the lateral incisors are too wide in
comparison with the central incisors
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testies to periodontal fragility.
The EG revealed asymmetrical gingi-
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val contours at the maxillary incisors be-
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tween the right and the left side (Fig 18d).

Summary
Thanks to the Decision-Making Table,
this patients smile analysis showed the
need for a global rehabilitation, which
required an accurate esthetic study using the Esthetic Guide.4 The red crosses
symbolize abnormalities, and the blue

represent normality.
Treatment plan
Of course, various treatment options are
available, but it should be remembered
that the best solution for the patient is
always the least invasive. Also it should
always be asked if an irreversible prepa-
ration of the teeth could be avoided by

an orthodontic treatment. When this is
not possible, the golden rule is to show
a preference for composite restorations
Fig 19 (a and b)
The orthodontist carries out
a functional set-up to reposition the upper incisorcanine group; in this way, a simulation of the desired
orthodontic treatment can be obtained.
over veneers, and veneers over crowns,

etc.
By referring to the results of the es-
maxillary incisors: buccal inclination
thetic analysis, it is essential to take a
increased by 5 degrees (class III
multidisciplinary approach to the treat-
compensation), correct sagittal and
ment:
vertical position
anterior guidance: lack of canine
1. Occlusion
guidance and incisal guidance too
Analysis
steep.
no history of trauma or previous orthodontic traction
Conclusion
behavior: clenching and bruxism
A behavioral rehabilitation, reinforced
skeletal relationship: class III, skel-
by wearing a relaxing night guard, al-
etal open-bite
lows for the correction of bruxism and
centric relation: incisal midline dis-
crispation parafunctions. The occlusal
placed 2 mm to the right, stable
analysis will determine the prosthodon-
centric occlusion
mandibular incisors: normal occlusion relationship
tic reconstruction criteria:

strict preservation of the maximal
inter-incisal opening (good, stable
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Fig 20 (a and b)
Using this setup, a functional waxup of the palatine surfaces indicates by how much
it is possible to extend the free edges while respecting functionality, and to reconstruct a correct anterior
guidance (according to the instructions of the occlusal analysis). Finally, a minimally invasive treatment
was chosen for this patient, with veneers instead of crowns, using orthodontic treatment to recreate the
anterior functions.
posterior bite) and the occlusal verti-
3. Periodontics
cal dimension
Taking account of the gingival biotype
preservation of the bite plane and

the Spee curve
of 13 and 23, a gingival thickening (by

means of a subepithelial connective tis-
rearrangement of the maxillary an-
sue graft) will be necessary beforehand,
terior teeth with bilateral equilibra-
as well as a lengthening of the crowns at
tion of the propulsion, with a view
the 12-11 level, with the aim of harmoniz-
to achieving an effective cuspidal
ing the general situation of the gingival
guidance (Fig 20).
margins. Finally, gingival palatine thinning will be required in order to free the
2. Orthodontics
incisor cingulums.
After positioning 13 and 23 on the arch,

these teeth will be moved back in order
4. Bleaching
to x them in the best position in relation
The choice of an ambulatory technique
to the opposing arch.
seemed most appropriate.
However, the class III tendency of this

patient implies a progressive increase in
5. Prosthetic reconstruction
the initial buccal position of the incisors,
Within the framework of an esthetic and
in tandem with the closing of the diaste-
harmonious restoration of the smile, por-
ma. This is why, in accordance with future
celain veneers were the obvious choice
prosthetic rehabilitation, it is essential to
thanks to their optical quality and the re-
nd the right compromise between an
spect shown to the tissue during prepa-
excessively pronounced buccal version
rations.
and oversized diastema. It is here that

the notion of esthetic corridor is most important (Fig 21).
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Fig 21 (a to c)
These pictures show the intraoral
orthodontic appliances, the distribution of the diastema and the compromise between the function
and esthetics. Such a treatment cannot be nalized
by orthodontic treatment alone.
Previsualization of the smile
Prior to any kind of treatment, and taking the importance of anomalies into ac-
There can be some difference between
count, a precise occlusal study is nec-
the patients mental image, the words
essary.
used to express this, and how they are

understood. It is therefore essential to
Initial conditions
give the patient a material idea of the
The
treatment, and this is why a previsualiza-
combined their requirements in order to
tion of the smile is recommended.11 This
design a setup, which was both func-
therapeutic strategy makes it possible to
tional and esthetic.
occlusodontist
and
orthodontist
demonstrate the future treatment, and to

assess the proposition in a concrete and
Diagnostic waxup
life-sized way prior to preparing the teeth.
Using the dental model, a waxup was
It not only claries the practitioners
made, preguring the ideal morphol-
reasoning, but also gives the patient the
ogy.12 It is the rst materialization of the
possibility to express his/her approval
esthetic project, since it informs the cli-
or reservations in an enlightened man-
nician of the esthetic changes possible
ner throughout the various prosthetic
in terms of future shapes and propor-
sequences.
tions, taking account of the phonetic and
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Fig 22 (a and b)
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b
Taking account of the patients wishes, these waxups demonstrate the appearance of
a convex and symmetrical esthetic plan, an increase in the length of the teeth, and a reduction in the width
of the lateral incisors, hidden by a mesial inclination in relation to the initial situation.
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Fig 23 (a to c)
Initial situation.
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patient, the objective of the treatment
occlusal data. In the case of this young

was to give her a powerful smile, by re-
Using the esthetic study, all data is col-
inforcing the dominance of the central
lected in order to develop a coherent EP.
incisors within a more feminine dental

composition (Fig 22).
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Esthetic Project (EP)
ss e n c e
Favoring realization in the mouth of

the diagnosis and treatment plan, the
EP constitutes an essential step in the
Esthetic project
prosthetic rehabilitation.
Using resin mock-ups xed to the un-
Computerized previsualization
A virtual elaboration of the treatment de-
prepared teeth, the EP allows the patient
sired allows patients to visualize the re-
and laboratory technician to objectify
sult, which is motivating and reassures
the anticipated effect of the future res-
them in their
choice.13
toration.12
This computerized approach, rein-
It represents a sketchbook, allowing
forced with a laboratory procedure (Figs
the practitioner to test the esthetic prop-
23 and 24), thereby strengthens com-
osition and validate it with the patient be-
munication between the medical team,
fore any irreversible clinical steps have
the patient, and the laboratory techni-
been taken, hence its importance. Using
cian (Fig 25).
the esthetic and functional waxup, there

are two ways of realizing this project that
follow below.
Fig 24 (a to c)
Esthetic setting: using the ortho-
dontic setup and the functional waxup, the gingival level is redesigned and the buccal surfaces are
remodeled in accordance with the ideal morphology and the dimensions determined by the Esthetic
Guide.
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Fig 25 (a to d)
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Computer simulation: using this wax previsualization, and thanks to the photographs
made to the same scale, this tool facilitates insertion of the modied teeth under the patients lips. The
patient can see in advance the real result of the project.
a
Fig 26 (a to d)
Direct esthetic project: using a transparent silicone splint moulded on to the corrected
dental model, this procedure uses an automolding technique and, as its name suggests, is performed
directly in the mouth.
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c
Fig 26 (a to d)
continued.
Fig 27 (a to d)
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Modifying the shape of the central incisors allows them to play a major role within the
framework of the smile. The axis of the lateral incisors in relation to the canines has been modied, thereby
reinforcing the esthetic value of the central incisors.
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Fig 28 (a to d)
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Indirect esthetic project: Using this waxup and following the indications given in the
esthetic analysis, the laboratory prepares eight ne shells made of stratied composite resin, measuring
0.2 to 0.3 mm. These mock-ups are then transferred to the unprepared teeth.
Direct esthetic project
the patient will therefore be closer to re-
Based on a waxup, this project is real-
ality (Fig 28).
ized directly in the mouth, following a
The nal esthetic project on eight
classic automolding technique. How-
teeth responds perfectly to the expec-
ever, using a resin whose surface ap-
tations voiced by the patient during the
pearance is relatively crude runs the risk
clinical examination (Fig 29).
of disappointing demanding patients

(Figs 26 and 27).
Preparation of teeth
impression stage
Indirect esthetic project

Using a more sophisticated material,
This stage is delicate in technical terms,
which resembles the nal ceramic more
and demands great meticulousness.
closely, the mock-ups offer a more natu-
Indeed, over-preparation leads to a
ral result. The illustration presented to
pointless mutilation, which can only be
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Fig 29 (a to d)
Note the more feminine cut, softer around the free edges.
offset by a thick layer of ceramic, giv-
Contour shapes
ing the nal restoration an articial ap-
Preparations without a palatine inva-
pearance.14 In the case of under-prep-
sion are carried out. Using the silicone
aration, it is difcult to correct any poor
guide, which allows visualization of the
positioning.
shape and position desired, reduction
Reduction keys are therefore a precon-
is performed according to the principle
dition to any preparation. Consequently,
of controlled penetration. Indeed, the
these guides allow the operator to esti-
preparation, guided by grooves whose
mate and check reduction volumes, in
depth is obtained using a calibrated bur,
order to make homothetic preparations
must not exceed the contact points on
in the volume pertaining to the nal res-
the proximal surfaces, and nish with a
toration, rather than to the initial dental
very ne butt margin at the level of the
volume. This allows for maximum con-
incisal edge.
servation of
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tissue14
(Figs 30 and 31).
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Fig 30 (a and b)
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b
The book-page key, sectioned horizontally, allows the entire preparation to be visual-
ized from the incisal edge to the neck.15
a
Fig 31 (a and b)
b
Individual guides allow for production of the quantity of buccal tissue eliminated inside
the mouth and on the occlusal surface.
Impression
Temporary veneers using
Since the preparation limits are most
mock-ups
often supra- or juxta-gingival, making

the impression is not a serious chal-
The aim of this procedure is to conserve
lenge.16 Taking account of the esthetic
the reconstruction criteria established
impact in this region, the method used
beforehand during the esthetic project,
must be the least traumatic possible,
and to combine it with the advantages of
hence the choice of a double-mix im-
elaboration using the indirect method, in
pression technique, used together with
order to easily obtain quality temporary
a thin retraction cord.
elements (Figs 3238).
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Fig 32
This method of making a temporary veneer is straight-
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mask
forward, consisting of adding three elements: the diagnostic

mock-up, prepared during the EP, whose esthetic criteria have
been validated, and the mock-up, combined with a rebasing
material, is held in the correct position by means of a silicone
key. In this case, the choice of a photopolymerizable resin facilitates time management, since the operator can control the
rebasing resin
repositioning key
nal polymerization.
Fig 33 (a to d)
This key is indispensable, because it creates a partial buccal support in which the masks
can be bonded, and a broad palatine support that acts as a general stabilizer and avoids an overow of
resin in this direction.
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Fig 34 (a to c)
The prepared surfaces are coat-
ed with a lm of glycerine. Rebasing of mock-ups

is performed by injection of resin directly onto the
dental surfaces and in the sandblasted interior of
the models. Controlled application is accomplished
c
Fig 35
thanks to the repositioning key.
Using an ordinary spatula, the elasticity
of the resin allows for easy removal of buccal excesses.
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Fig 36
Potential interproximal excesses are cut
out to allow for reinsertion.
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Fig 37
Final photopolymerization.
Fig 38
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Disinsertion: it is advisable to remove the
entire block in such a way as to allow mechanical

locking during its sealing.
Fig 39 (a and b)
In this way, one can obtain replicas, which are true to the future restoration and a new
smile, which is then submitted for the patients approval.
This method of converting the masks

into temporary veneers requires the
making of an occlusal repositioning key,
which will guide the reinsertion of the
mock-ups in the correct position at the
rebasing stage.
Transitional restorations are not to be
neglected: by allowing both the patient
and practitioner to validate the EP in
concrete terms,3 they play a major role
in the preguration of the denitive res-
Fig 40
toration16,17 (Fig 39).
dam), the practitioner is able to resolve problems of
Thanks to this method (individual rubber
insulation and contamination.
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Fig 41 (a and b)
The diastemata of the upper jaw have been rearranged and signicantly reduced.
a
Fig 42 (a and b)
These photographs highlight a feminine and youthful dental composition.
a
Fig 43 (a and b)
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b
In accordance with the guiding esthetic principles, the smile line ts harmoniously with
the curve of the lower lip even if the correction of the dental midline had not orthodontically been possible.
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Prosthetic tting
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The eight biscuits are tested. At this

stage, it is possible to analyze any potential corrections to be made, and to
convey these modications to the laboratory.11 The veneers were made of
feldspathic ceramic at the laboratory in
order to obtain the most esthetic result.
Verication criteria at the clinical-
tting stage:
Fig 44 (a to c)
accuracy of marginal adaptation
must never underestimate the impact.
When changing a smile, one
inspection of contact points

adherence to esthetic project: validation of shape, color, proportions,
transition lines, macro- and microgeography, and shape of the incisor
edges.
Bonding
Using an individual rubber dam11 greatly
facilitates the clinical stage of the bonding procedure (Fig 40). The bonding
procedure follows a standard protocol
consisting of three stages:
preparation of the veneer: etching,
silanization, adhesive
preparation of the tooth: sandblasting, etching, primer, then adhesive

bonding: because of the implementation of the individual rubber dam,
excesses are easily removed, and
there is zero risk of overow onto the
neighboring teeth.
Clinical results
Since the photographic protocol used
before and after operating is identical,
the similarity of the nal porcelain creations to the images of the transitional veneers is apparent.
73
Q ui
by N
ht
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No Co
t fo
rP
ub
lica
ti
te smile on
pectations. Reconstructing a pretty
ss e n c e
ot
Conclusion
fo r
gives patients more than just a healthy

This account of a clinical case, which can
and attractive appearance; it also pro-
be considered exemplary, is intended to
vides a mental boost, which has a posi-
show the need for a rational approach to
tive effect on how they see themselves.
all esthetic smile-restoration projects.

By resorting rst to the Decision-Making Table and later to the Esthetic Guide
Additional resources
in order to establish the diagnosis and

treatment plan, it is possible to success-
The
fully perform all of the stages, which lead
present clinical case is available in pdf
to the result shown in the photographs
format by request to richter@quintes-
above (Figs 4144).
senz.de.
Esthetic
Guide
featured
in
the
The patients expression shows that

her
requests
regarding
an
esthetic,
functional, and, most of all, personalized
Acknowledgements
rehabilitation have been respected.

Each individual represents a specic
Pierre Andrieu (dental laboratory, MOF); Profes-
case, and it would not be possible to
sor Francis Louise (periodontics); Professor Jean-
perform a standard restoration without

insulting the patients personality and ex-
References
1.
2.
3.
4.
5.
6.
Graber LW, Lucker GW.

Dental esthetics self evaluation and satisfaction. Am J
Orthod 1980;77:163-178.
Terry RL, Davis JS. Components of facial attractiveness. Percept Mot Skills
1978;42:918-919.
Paris JC, Faucher AJ, Makarian MH. Smile Aesthetics:
Integration or Rehabilitation?
Ral Clin 2003;14:367-378.
Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics: Esthetic Analysis.
Chicago: Quintessence
Publishing, 2004.
Talarico G, Morgante E.
Psychology of dental esthetics: dental creation and the
harmony of the whole. Eur J
Esthet Dent 2006;4:303-312.
Paris JC, Faucher AJ. Le
Guide Esthtique. Paris:
Quintessence International,
2004
Simon (orthodontics).
Operator: Professor Andr-Jean Faucher.
7.
Chiche GJ, Pinault A. Esthetics of anterior xed prosthodontics. Chicago: Quintessence Publishing, 1994.
8. Fradeani M. Evaluation of
dentolabial parameters as
part of a comprehensive
esthetic analysis. Eur J
Esthet Dent 2006;1:62-69.
9. Rufenacht CR. Fundamentals of Esthetics. Chicago:
Quintessence Publishing,
1990.
10. Duarte S, Lorezon AP, Schnider P. The Importance of
width/length ratios of maxillary anterior permanent teeth
in esthetic rehabilitation. Eur
J Esthet Dent 2008;3:224234.
11. Magne P, Magne M, Belser
U. The diagnostic template:
a key element to the comprehensive esthetic treatment
concept. Int J Periodontics
Restorative Dent 1996;16:
560-569.
12. Faucher AJ, Magneville B,
Watine F, Koubi G, Brouillet
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JL. Provisional facets and

Aesthetic Project. Ral Clin
1994;5:25-33.
Goldstein CE, Goldstein
RE, Garber DA. Imaging in
esthetic dentistry. Chicago:
1988.
Grel G. The Science and
Art of Porcelain Laminate
Veneers. Chicago: Quintessence Publishing, 2003.
Magne P, Belser U. Bonded
Porcelain Restorations in the
Anterior Dentition: A Biomimetic Approach. Chicago:
2003.
Derrien G. Provisional
restorations with compound
prosthetics. CdP 1991;73:6774.
Rieder CE. Use of provisional
restorations to develop and
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Jean-Christophe Paris, DMD

Stphanie Ortet, DMD

Annick Larmy, DMD

Jean-Louis Brouillet, DMD, DDS

Correspondence to: Dr Jean-Christophe Paris

for Success in a Complex Case

Smile Esthetics: a Methodology

The clinical case presented is the dem-

ing of the smile. This type of multidisci-

plinary treatment, which seems compli-

proach to a complex treatment. A pre-

cated at rst, is greatly simplied once

cise methodology is important to ensure

time has been spent on the diagnosis

that the treatment objectives are clear

and treatment plan: it thereby becomes

to all the teams. The aim of the treat-

a succession of clinical stages.

ment is to restore dentofacial harmony

(Eur J Esthet Dent 2011;6:5074)

a weapon of seduction, the primary

The smile can be a snapshot of the soul,

The Decision-Making Table

means of communication, a reection of

By referring to the Decision-Making Ta-

personality so many denitions, which

ble3, it is possible to analyze a smile in

underline the essential role of the smile

its entirety and approach a case study in

in expression and communication be-

a precise and methodical way.

tween human beings.

Using the guiding principles, which

The direct relationship between the

govern smile esthetics, the Decision-

beauty of the smile and self-esteem

Making Table (Fig 1) is a therapeutic tool

should also be mentioned, an extremely

that allows the clinician to reinforce an

important notion regarding the quality of

esthetic diagnosis and treatment plan.5

ones socio-professional life.1-3

Indeed, this evaluation of esthetic crite-

These reections afrm that the es-

ria is more than just an analysis of the

thetic restoration of the patients smile

dental composition. It also includes the

is an essential medical act. It can never

gingival tissues and the nal esthetic

be approached with anything less than

restoration in the framework of the smile

a perfectly codied method, which rules

and face, taking into account the pa-

out failure, even if the success is not

Thus, during an esthetic consultation,

This method consists of a checklist,

this guide quickly brings to light any lo-

which brings together all esthetic and

calized problems which will be treated

functional parameters. It claries and

and assimilated into an initially-harmo-

facilitates the work of clinicians, so that