Post Orthodontic Cosmetic Detailing , Authors: Dr. Sharmada. B.K MDS Orthodontics and Dentofacial Orthopedics Senior Lecturer, Vydehi Institute of Dental Sciences and Research Centre, Bangalore Email: drsharmada@gmail.com Dr. Sandesh.S.Pai MDS Orthodontics and Dentofacial Orthopedics Professor and HOD, Vydehi Institute of Dental Sciences and Research Centre, Bangalore Email: sandyspai@rediffmail.com Dr.Santosh. A.N MDS Oral and Maxillofacial surgery Assistant Professor at Ashwini Medical College and Research Centre, Sholapur Email: drsantosh_n@yahoo.co.in Dr. Vishvanath.A.E MDS Orthodontics and Dentofacial Orthopedics Reader, Vydehi Institute of Dental Sciences and Research Centre, Bangalore E mail: drvishvanathortho@yahoomail.co.in Key words: bleaching, diode laser, gingival contouring, micro abrasion, veneers, white spot lesions Corresponding author e mail id: drsharmada@gmail.com Fax. No: 080-28412956 Abstract: Cosmetic detailing has become important for orthodontists because most patients evaluate the outcome of treatment by their smiles and the overall enhancement in their facial appearance. The purpose of this article is to examine some cosmetic ideas and present ways in which we can improve the smiles of orthodontic patients. Certain factors which would aid in the cosmetic enhancement of the patient, include, gingivectomy, gingivoplasty , bleaching, veneers, selective contouring, bridges and cosmetic build ups. Introduction: Cosmetic detailing has become important for orthodontists because most patients evaluate the outcome of treatment by their smiles and the overall enhancement in their facial appearance. Although orthodontic treatment is based primarily on occlusal relationships, greater attention is now paid to enhancing dentofacial characteristics to produce optimal facial esthetics.1 The Ideal Smile exposes three quarters of the crown height, though up to 2-4mm of gingival exposure is considered aesthetic. The incisal and gingival exposure is more in females than in males. The Smile Arc refers to the curvature of maxillary incisors which is parallel to the lower lip upon smile. 2 Figure 1 shows the ideal smile arc. Fig.1 Smile arc Contemporary orthodontic smile analysis is generally defined in terms of tooth shape and proportions, gingival aesthetic characteristics, aesthetic teeth and gingival relationships. The purpose of this article is to examine some cosmetic ideas and present ways in which we can improve the smiles of orthodontic patients Gingival aesthetics Two concepts of cosmetic dentistry that are important to the final aesthetic outcome of orthodontic patients are gingival shape and gingival contour. Gingival shape refers to the curvature of the gingival margin of the tooth, determined by the cementoenamel junction and the osseous crest. The gingival shape of the mandibular incisors and the maxillary laterals should exhibit a symmetrical half oval or half-circular shape. The maxillary centrals and canines should exhibit a gingival shape that is more elliptical. The gingival zenith (the most apical point of the gingival tissue) is located distal to the longitudinal axis of the maxillary centrals and canines. The gingival zenith of the maxillary laterals and mandibular incisors should coincide with their longitudinal axis.Figure 2 shows the Gingival zenith of centrals, laterals and canines. Fig. 2 Gingival zenith Gingival contour, as compared with gingival shape, refers to a more 3-dimensional description of gingival topography. Ideal gingival contour is characterized by sharp interdental papillae and equally tapered gingival margins at the cervical margin of the teeth.2 Figure 3 shows the gingival shape and contour. Fig; 3 Gingival shape and contour Cosmetic gingival contouring using soft tissue lasers The uses of soft tissue lasers in orthodontic practice include crown lengthening, idealizing tooth proportionality, and resolving crown height asymmetries. Hypertrophic gingival margins are often seen in orthodontic treatment secondary to marginal gingival inflammation, both acute and chronic. The hypertrophic papillae can be ablated and the rolled gingival margins can be bevelled to sharpen their contour adjacent to the crown of the tooth. Figure 4 shows the diode laser. Fig. 4 Diode laser Bracket placement depends on the final incisor placement in the dynamic smile, determined by both the incisal edge and the gingival margin. It is therefore important to be able to visualize the crown in ideal proportion before bracket placement. Another excellent application of crown lengthening is when a canine is substituted for a congenitally missing lateral incisor. When the first premolar is moved into the canine position, its crown height looks too short. Soft tissue laser technology can also be used in cosmetic gingival contouring, frenectomy, removal of mucocutaneous lesions, and gingival sculpting.5 In patients who require large amounts of space closure, often the gingival tissue becomes redundant in the interdental spaces. This problem, is exacerbated by poor oral hygiene, which is largely a function of the amount of space closure. A vicious circle can develop, whereby the patient’s poor hygiene results in swollen gingival tissues, and then the patient will not brush and floss adequately because of bleeding and discomfort. In this situation, we might remove redundant tissue to eliminate the inflammation, creating gingival contours that are again amenable to cleaning. Once the tissue has healed, the patient is likely to maintain better oral hygiene. Anaesthetic gingival contours, yield a cosmetic result after laser contouring.6 White spot lesions and Enamel micro abrasion Enamel decalcification regrettably affects many post orthodontic patients. It is primarily seen in those whose intra-treatment compliance with oral hygiene and preventive advice is poor. Decalcification occurs in areas of plaque accumulation and is predominantly closely associated with orthodontic bands and brackets. Post orthodontic white lesions have been found to affect between 2% and 96% of patients. As the lesion progresses, aesthetics can become adversely affected, especially if secondary staining occurs.7 Micro abrasion has many applications and has been widely used for the removal of superficial non-carious enamel defects. Recently, the technique has also been advocated for the removal of post orthodontic demineralized white lesions. Enamel micro abrasion is a conservative aesthetic treatment used for the selective removal of localized areas of intrinsically stained superficial enamel, usually caused by mild fluorosis and/or enamel hypoplasia or white spot lesion. Micro abrasion works best to remove unpleasant stains that are localized in the outermost part of the dental enamel. It also can be combined with tooth whitening to achieve an even more esthetic result. It is proven that the micro abrasion procedure produced a smooth, mineral rich enamel surface. After enamel micro abrasion, remineralizing agents, like CPP-ACFP and β-TCP were used for the remineralization of micro abraded enamel.8 Other procedures to enhance aesthetics , post-orthodontically include bleaching, veneers, partial bridges and pontics Discoloured teeth can be managed by the application of a chemical agent to oxidize the organic pigmentation in the tooth is referred to as bleaching. Most bleaching techniques involve hydrogen peroxide in different concentrations. Veneers include a layer of tooth-colored material that is applied to the tooth for esthetically restoring localized or generalized defects or intrinsic discolorations. Partial veneers are indicated for restoration of localized defects or areas of intrinsic discoloration. Full veneers can be indicated for Restoration of generalized defects or areas of intrinsic discoloration.9 Summary and Conclusion: Enhancement of facial beauty is one of the primary elective goals of patients seeking orthodontic care. The goal of orthodontic treatment should be the attainment of the best possible esthetic result. In order to achieve an ideal smile, it is not sufficient to work on the dental units alone. We also need to concentrate on certain factors which would aid in the cosmetic enhancement of the patient, which include, gingivectomy, gingivoplasty , bleaching, veneers, selective contouring, bridges and cosmetic build-ups. References 1.Erdal Is¸ ıksal,a Serpil Hazar,b and Sercan Akyalçınc,;Smile esthetics: Perception and comparison of treated and untreated smiles, J Orthod Dentofacial Orthop 2006;129:8-1 2. David M. Sarver; The importance of incisor positioning in the esthetic smile: The smile arc; American Journal of Orthodontics and Dentofacial Orthopedics ;Volume 120, Number 2 3. David M. Sarver, Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth, American Journal of Orthodontics and Dentofacial Orthopedics December 2004 4. American Academy of Cosmetic Dentistry. Diagnosis and treatment evaluation in cosmetic dentistry—a guide to accreditation criteria. Madison: American Academy of Cosmetic Dentistry 5. David M. Sarver and Mark Yanosky; Principles of cosmetic dentistry in orthodontics: Part 2. Soft tissue laser technology and cosmetic gingival contouring; American Journal of Orthodontics and Dentofacial Orthopedics; January 2005 6. David M. Sarver and Mark Yanosky, Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems; American Journal of Orthodontics and Dentofacial Orthopedics, Volume 127, Number 2 7. Tania C. Murphy, Derrick R. Willmot, Helen D. Rodd; Management of postorthodontic demineralised white lesions with microabrasion: A quantitative assessment; American Journal of Orthodontics and Dentofacial Orthopedics;Volume 131, Number 1 8. Jones Mathias, Sathyakumar, Mahalaxmi; Comparison of surface roughness after micro abrasion of enamel using two proprietary remineralization agents: An in–vitro study; Kerala Dental Journal; Vol.34, No. 4, October 2011 9. Alex Jacobson; The art of the smile: Integrating prosthodontics, orthodontics, periodontics, dental technology, and plastic surgery in esthetic dental treatment; American Journal of Orthodontics and Dentofacial Orthopedics, November 2005 , http://bit.ly/177bBT3

Post Orthodontic Cosmetic Detailing , Authors: Dr. Sharmada. B.K MDS Orthodontics and Dentofacial Orthopedics Senior Lecturer, Vydehi Institute of Dental Sciences and Research Centre, Bangalore Email: drsharmada@gmail.com Dr. Sandesh.S.Pai MDS Orthodontics and Dentofacial Orthopedics Professor and HOD, Vydehi Institute of Dental Sciences and Research Centre, Bangalore Email: sandyspai@rediffmail.com Dr.Santosh. A.N MDS Oral and Maxillofacial surgery Assistant Professor at Ashwini Medical College and Research Centre, Sholapur Email: drsantosh_n@yahoo.co.in Dr. Vishvanath.A.E MDS Orthodontics and Dentofacial Orthopedics Reader, Vydehi Institute of Dental Sciences and Research Centre, Bangalore E mail: drvishvanathortho@yahoomail.co.in Key words: bleaching, diode laser, gingival contouring, micro abrasion, veneers, white spot lesions Corresponding author e mail id: drsharmada@gmail.com Fax. No: 080-28412956 Abstract: Cosmetic detailing has become important for orthodontists because most patients evaluate the outcome of treatment by their smiles and the overall enhancement in their facial appearance. The purpose of this article is to examine some cosmetic ideas and present ways in which we can improve the smiles of orthodontic patients. Certain factors which would aid in the cosmetic enhancement of the patient, include, gingivectomy, gingivoplasty , bleaching, veneers, selective contouring, bridges and cosmetic build ups. Introduction: Cosmetic detailing has become important for orthodontists because most patients evaluate the outcome of treatment by their smiles and the overall enhancement in their facial appearance. Although orthodontic treatment is based primarily on occlusal relationships, greater attention is now paid to enhancing dentofacial characteristics to produce optimal facial esthetics.1 The Ideal Smile exposes three quarters of the crown height, though up to 2-4mm of gingival exposure is considered aesthetic. The incisal and gingival exposure is more in females than in males. The Smile Arc refers to the curvature of maxillary incisors which is parallel to the lower lip upon smile. 2 Figure 1 shows the ideal smile arc. Fig.1 Smile arc Contemporary orthodontic smile analysis is generally defined in terms of tooth shape and proportions, gingival aesthetic characteristics, aesthetic teeth and gingival relationships. The purpose of this article is to examine some cosmetic ideas and present ways in which we can improve the smiles of orthodontic patients Gingival aesthetics Two concepts of cosmetic dentistry that are important to the final aesthetic outcome of orthodontic patients are gingival shape and gingival contour. Gingival shape refers to the curvature of the gingival margin of the tooth, determined by the cementoenamel junction and the osseous crest. The gingival shape of the mandibular incisors and the maxillary laterals should exhibit a symmetrical half oval or half-circular shape. The maxillary centrals and canines should exhibit a gingival shape that is more elliptical. The gingival zenith (the most apical point of the gingival tissue) is located distal to the longitudinal axis of the maxillary centrals and canines. The gingival zenith of the maxillary laterals and mandibular incisors should coincide with their longitudinal axis.Figure 2 shows the Gingival zenith of centrals, laterals and canines. Fig. 2 Gingival zenith Gingival contour, as compared with gingival shape, refers to a more 3-dimensional description of gingival topography. Ideal gingival contour is characterized by sharp interdental papillae and equally tapered gingival margins at the cervical margin of the teeth.2 Figure 3 shows the gingival shape and contour. Fig; 3 Gingival shape and contour Cosmetic gingival contouring using soft tissue lasers The uses of soft tissue lasers in orthodontic practice include crown lengthening, idealizing tooth proportionality, and resolving crown height asymmetries. Hypertrophic gingival margins are often seen in orthodontic treatment secondary to marginal gingival inflammation, both acute and chronic. The hypertrophic papillae can be ablated and the rolled gingival margins can be bevelled to sharpen their contour adjacent to the crown of the tooth. Figure 4 shows the diode laser. Fig. 4 Diode laser Bracket placement depends on the final incisor placement in the dynamic smile, determined by both the incisal edge and the gingival margin. It is therefore important to be able to visualize the crown in ideal proportion before bracket placement. Another excellent application of crown lengthening is when a canine is substituted for a congenitally missing lateral incisor. When the first premolar is moved into the canine position, its crown height looks too short. Soft tissue laser technology can also be used in cosmetic gingival contouring, frenectomy, removal of mucocutaneous lesions, and gingival sculpting.5 In patients who require large amounts of space closure, often the gingival tissue becomes redundant in the interdental spaces. This problem, is exacerbated by poor oral hygiene, which is largely a function of the amount of space closure. A vicious circle can develop, whereby the patient’s poor hygiene results in swollen gingival tissues, and then the patient will not brush and floss adequately because of bleeding and discomfort. In this situation, we might remove redundant tissue to eliminate the inflammation, creating gingival contours that are again amenable to cleaning. Once the tissue has healed, the patient is likely to maintain better oral hygiene. Anaesthetic gingival contours, yield a cosmetic result after laser contouring.6 White spot lesions and Enamel micro abrasion Enamel decalcification regrettably affects many post orthodontic patients. It is primarily seen in those whose intra-treatment compliance with oral hygiene and preventive advice is poor. Decalcification occurs in areas of plaque accumulation and is predominantly closely associated with orthodontic bands and brackets. Post orthodontic white lesions have been found to affect between 2% and 96% of patients. As the lesion progresses, aesthetics can become adversely affected, especially if secondary staining occurs.7 Micro abrasion has many applications and has been widely used for the removal of superficial non-carious enamel defects. Recently, the technique has also been advocated for the removal of post orthodontic demineralized white lesions. Enamel micro abrasion is a conservative aesthetic treatment used for the selective removal of localized areas of intrinsically stained superficial enamel, usually caused by mild fluorosis and/or enamel hypoplasia or white spot lesion. Micro abrasion works best to remove unpleasant stains that are localized in the outermost part of the dental enamel. It also can be combined with tooth whitening to achieve an even more esthetic result. It is proven that the micro abrasion procedure produced a smooth, mineral rich enamel surface. After enamel micro abrasion, remineralizing agents, like CPP-ACFP and β-TCP were used for the remineralization of micro abraded enamel.8 Other procedures to enhance aesthetics , post-orthodontically include bleaching, veneers, partial bridges and pontics Discoloured teeth can be managed by the application of a chemical agent to oxidize the organic pigmentation in the tooth is referred to as bleaching. Most bleaching techniques involve hydrogen peroxide in different concentrations. Veneers include a layer of tooth-colored material that is applied to the tooth for esthetically restoring localized or generalized defects or intrinsic discolorations. Partial veneers are indicated for restoration of localized defects or areas of intrinsic discoloration. Full veneers can be indicated for Restoration of generalized defects or areas of intrinsic discoloration.9 Summary and Conclusion: Enhancement of facial beauty is one of the primary elective goals of patients seeking orthodontic care. The goal of orthodontic treatment should be the attainment of the best possible esthetic result. In order to achieve an ideal smile, it is not sufficient to work on the dental units alone. We also need to concentrate on certain factors which would aid in the cosmetic enhancement of the patient, which include, gingivectomy, gingivoplasty , bleaching, veneers, selective contouring, bridges and cosmetic build-ups. References 1.Erdal Is¸ ıksal,a Serpil Hazar,b and Sercan Akyalçınc,;Smile esthetics: Perception and comparison of treated and untreated smiles, J Orthod Dentofacial Orthop 2006;129:8-1 2. David M. Sarver; The importance of incisor positioning in the esthetic smile: The smile arc; American Journal of Orthodontics and Dentofacial Orthopedics ;Volume 120, Number 2 3. David M. Sarver, Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth, American Journal of Orthodontics and Dentofacial Orthopedics December 2004 4. American Academy of Cosmetic Dentistry. Diagnosis and treatment evaluation in cosmetic dentistry—a guide to accreditation criteria. Madison: American Academy of Cosmetic Dentistry 5. David M. Sarver and Mark Yanosky; Principles of cosmetic dentistry in orthodontics: Part 2. Soft tissue laser technology and cosmetic gingival contouring; American Journal of Orthodontics and Dentofacial Orthopedics; January 2005 6. David M. Sarver and Mark Yanosky, Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems; American Journal of Orthodontics and Dentofacial Orthopedics, Volume 127, Number 2 7. Tania C. Murphy, Derrick R. Willmot, Helen D. Rodd; Management of postorthodontic demineralised white lesions with microabrasion: A quantitative assessment; American Journal of Orthodontics and Dentofacial Orthopedics;Volume 131, Number 1 8. Jones Mathias, Sathyakumar, Mahalaxmi; Comparison of surface roughness after micro abrasion of enamel using two proprietary remineralization agents: An in–vitro study; Kerala Dental Journal; Vol.34, No. 4, October 2011 9. Alex Jacobson; The art of the smile: Integrating prosthodontics, orthodontics, periodontics, dental technology, and plastic surgery in esthetic dental treatment; American Journal of Orthodontics and Dentofacial Orthopedics, November 2005 , http://bit.ly/177bBT3 , via Dental Teach " Daily Dental Info " http://www.facebook.com/photo.php?fbid=595519927139227&set=a.588953107795909.1073741858.110664842291407&type=1