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An Expanded View of Excellence by Dr. Ilies Tibaoui

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Categories: Orthodontics;
An Expanded View of Excellence 

Microaesthetics that transform patient aesthetic outcomes

by Dr. Ilies Tibaoui

Traditional training led orthodontists toward our role in positioning teeth and jaws. To put it simply, we were taught to move teeth, and like many readers, I actively sought orthodontists who could teach skills that produced wonderful outcomes.

I had seen many skilled clinicians, but cases that truly stood out aestheticially were not common. In 2012 or 2013, I was introduced to Dr. Tom Pitts, and in his cases I found the combination of beautiful faces, beautiful smiles and beautiful teeth that illustrated Dr. David Sarver’s “macro-, mini- and microaesthetic” terminology.1

In 2014, I participated in a Pitts’ Masters in Finishing program to acquire the skills that got my cases within the ballpark of what I wanted to accomplish aesthetically. In the program, I learned about prebonding positive and negative coronoplasty to attain improved aesthetics quickly (Fig. 1) and the value of aesthetic finishing of both white and pink tissues.

Orthodontics and microaesthetics
Fig. 1: Prebonding coronoplasty, as described by Dr. Tom Pitts, improves both the alignment of the contact
points and aesthetic flow.

Most orthodontists who are familiar with Pitts’ approach to smile arc protection (SAP), vertical incisor display (VID) and bracket placement2 also know about prebonding negative coronoplasty of cuspids and bicuspids to improve alignment of the contact point of the dentition and flow in aesthetic presentation. Pitts also advocates prebonding positive coronoplasty to restore optimal tooth length before bonding.

To get the most beautiful results and make patients’ smiles stand out, I decided to acquire more knowledge about shaping teeth for aesthetic finishing. This led me to reconnect with dentistry, taking courses in cosmetic dentistry and digital smile design.3

One can’t help but be impressed with the aesthetic transformations achieved just by changing shape and color of teeth. Orthodontists frequently neglect this critical part of aesthetic outcomes, likely as a result of a lack of exposure during training and a lack of practical “how-to” training. The goals of this article:
  • To show how powerful microaesthetics can be in transforming results.

    •
  • To present a simple process adapted from cosmetic dentistry that orthodontists can follow to get more consistent results.

    •
  • To create the recognition that these techniques fall squarely into the orthodontic sphere of influence.

The aesthetic context
I prefer the term “white and pink aesthetics” instead of “microaesthetics” because the latter has been widely developed in the literature and my goal is not to add more complexity into the discussion.

For refinements in white and pink aesthetics to exert relevance, they must occur in the context of beautiful faces and beautiful smiles. This translates to “outside-in” diagnosis and treatment planning in a manner that begins with the end in mind and finishes with beauty.4

This concept is demonstrated in Figs. 2 and 3, which illustrate different methods of treating the same diagnosis of “short teeth.” For the patient in Figs. 2a and 2b, positive coronoplasty (addition of composite) was the right choice because the vertical incisor position (VIP) and vertical incisor display (VID) were appropriate while the smile arc (SA) was inadequate. For the patient in Fig. 3, negative gingivoplasty by diode laser gingival recontouring was the best choice because both VIP and SA were adequate.

Orthodontics and microaesthetics
Orthodontics and microaesthetics
Figs. 2a and 2b: Short teeth corrected by positive coronoplasty.

Orthodontics and microaesthetics
Fig. 3: “Short teeth” corrected by negative gingivoplasty.

In both cases, the tooth positions after orthodontics were acceptable, but failing to create beautiful teeth through optimizing white and pink aesthetics would not have satisfied the patient’s aesthetic need—and could be perceived as an aesthetic failure.

The first step in the treatment process should involve gaining an understanding of the patient’s aesthetic need as requiring:
  • Alteration in tooth position (VID/VIP, gingival display, smile arc).

    •
  • Changes in white (tooth) aesthetic contours.

    •
  • Changes in pink (gingival) aesthetic contours.
For clinicians early in this journey, there is value in creating visual aesthetic objectives using digital simulator software. Good apps for this purpose include Smilecloud, SmileFy and DSD Direct Hands- On.

Given the constraints of space, this article will be limited to developing whitetissue aesthetics.


 The white-tissue factor
Orthodontists have paid lip service to white-tissue aesthetics for decades. Most doctors incorporate the principles in only very specific cases, including peg laterals and canine substitution, while others expand it further by manicuring incisal edges at the end of some treatments, using mostly “revision through reduction.” By expanding our vision through a lens of tooth contour similar to that of a cosmetic dentist, we can deliver more attractive smiles by creating beautiful teeth.


Basic principles of aesthetic teeth
No single tooth shape or contour is universally ideal and applicable to all patients. Research has shown that the golden proportion, recurring aesthetic proportion and golden percentage methods are all inadequate at describing aesthetic contours of anterior teeth in aesthetic smiles.5 Similarly, the concept of visagism, frequently employed in digital smile design proponents to correlate tooth shape with personality type and smile projection, has not held up well under research scrutiny.6

Contour principle: Height/width ratio of 75%–85%, with length of the upper incisor less than 11.5 mm.

Shape principle: Avoid overly square or triangular incisors, with more rounded, softer shapes for female patients.

Virtually every orthodontist is familiar with Fig. 4a, which illustrates the white and pink aesthetic principles of SA, gingival arc (GA), papillary arc (PA), incisal embrasures, gingival embrasures and contact point lengths. However, fewer are familiar with Fig. 4b, which illustrates the relationships among reflective surfaces on the anterior teeth, gingival zeniths and long axis, incisal edge curvature, emergence profile and contact point escapements. These relationships, which are well known to our cosmetic dental colleagues, are integral factors in aesthetic tooth shape.

Orthodontics and microaesthetics
Figs. 4a and 4b: White and pink tissue relationships in aesthetic smiles.
(Images courtesy of Dr. Tom Pitts)

Aesthetic tooth shape then is an artistic choice, especially when it involves enhancing tooth shape in patients who are considering extensive restorative dentistry.

Color principle: Whiter teeth look more youthful and are preferred, with good uniformity of color (Fig. 5) and natural gradation.

Orthodontics and microaesthetics
Fig. 5: Aesthetic bonding to improve color uniformity.


The ability to alter tooth color has created an additional opportunity for orthodontists to deliver truly aesthetic results; many practices now offer in-house whitening as an adjunctive service. Given the trend of orthodontic patients being older and more discerning and demanding about their aesthetic outcomes, we can expect this trend to increase.7


A systematic approach to “white tissue” recontouring
After a few years of trying to teach the principles of microaesthetics, I realized rules and guidelines alone weren’t enough: Most orthodontists are more effective when following systematized techniques, so they know when to start and stop.

Some attempts at establishing techniques for aesthetic tooth contours have been published in dental journals8 but there have been few in orthodontic literature, so I’m grateful for the opportunity to address that.

The easiest, most reliable workflow was adapted from cosmetic dentistry protocols by Dr. Hicham Khayat. It involves seven steps: frontal plane, vertical plane, transversal line angles, embrasures, the three facial planes, macrotexture and microtexture. By adapting this technique to orthodontics, a systematized approach is attained.

1: Frontal plane. Aesthetic orthodontic alignment is designed to place the facial surface of the incisor vertically, so reflected light travels straight to the eye of the observer instead of being refracted when teeth are more proclined (Fig. 6). Prebonding coronoplasty recontouring of the facial surfaces makes the process more consistent.

Orthodontics and microaesthetics
Fig. 6: Upright teeth reflect light favorably for aesthetic perception.
(Images courtesy of Dr. Wassim Bouzid)


Fine adjustments to shape of reflective surfaces on the anterior teeth are easily accomplished with fine diamonds, flexible discs and polishing at bracket repositioning appointments and debonding.

Remember that tooth color affects aesthetic perception, too: Darker teeth appear to be set lingually even if they are well aligned, as seen in Fig. 7.

Orthodontics and microaesthetics
Fig. 7


2: Vertical plane. Aligning the vertical proportions of the teeth is the second step in the protocol. In orthodontics, this step is taken during treatment after correct VIP is attained, and facilitated by tooth shape optimization through positive or negative coronoplasty (Fig. 8).

Orthodontics and microaesthetics
Fig. 8: Positive coronoplasty through aesthetic bonding and negative
gingivoplasty with a diode laser can be used to establish harmony.
The key is that tooth position was optimal, and correcting contours
and tooth shape provided an optimal aesthetic result.


Optimizing aesthetic tooth proportions after adjusting gingival display and tooth length using interproximal reduction (IPR) is accomplished with discs, followed by flexible discs and polishing.

I share with cosmetic dentists a view that anterior tooth height-to-width proportions of 75%–78% are most attractive.

I also agree with Pitts’ assertion that anterior teeth should have long contacts that extend below gingival margins, to avoid development of black triangles as the tissue recedes. In adult patients where slenderizing in excess of aesthetic proportions would be required to eliminate black triangles, injectable resins and BioClear matrix systems are very useful to establish aesthetic and hygienic interproximal contacts.

3: Transitional line angles. In my experience, this is one of most neglected steps when orthodontists perform IPR. Orthodontists often leave flat proximal surfaces after IPR and fail to appreciate the role the transition from the facial surface to the interproximal contact has in natural tooth shape and aesthetics. In cosmetic dentistry, this is called “flow.”

I recommend using a flexible disc on a slow-speed handpiece to restore transitional line angles after IPR procedures. This avoids the appearance of teeth being “bonded together.” Fig. 9 illustrates a situation that required IPR to smooth the transitional line angles and get an aesthetic final result.

Orthodontics and microaesthetics
Fig. 9


4: Insical embrasures. Once transitional line angles and contacts have been refined, incisal embrasures can be detailed. Research has indicated that orthodontists understand the aesthetic benefits of semirounded embrasure forms in both men and women.9 Careful attention to the rounded shape of incisal edges can bring “youthfulness” to a smile, as seen in the pairing of Fig. 10.

Orthodontics and microaesthetics
Fig. 10


5: The three facial contours. Just as the buccal surface is not flat from mesial to distal, nor is it flat from the gingival to the incisal edge. Attention must be paid to these contours for light reflection. As seen in Fig. 11, the facial surface of the incisor is slightly curved occlusogingivally for optimal light reflection. Perfecting these contours is a vital step in optimizing aesthetics.

Orthodontics and microaesthetics
Fig. 11: (Images courtesy of Dr. Wassim Bouzid)


6,7: Macro- and microaesthetic texturing. Resorting to adjustments of macro- and microaesthetic textures is rarely required, but it gains greater importance when restoring small lateral incisors by positive coronoplasty or adjusting tooth shapes during cuspid substitution.


Case study
The patient in Fig. 12 was seeking aesthetic improvement for her smile. While her orthodontic situation was not complex, creating beautiful teeth along with a beautiful smile presented some challenges.

Orthodontics and microaesthetics
Fig. 12


Her smile (Fig. 13) had inadequate maxillary transverse deficiency, further complicated by previous extractions of four bicuspids. She displayed good VIP/ VID, which made things more straightforward. In considering the principles of tooth contour and tooth shape, her central incisor tooth proportions were closer to 80% than 75% (which would have been more attractive), connectors were poor, the incisal edges were flat and the teeth were very triangular in shape.

Orthodontics and microaesthetics
Fig. 13


Improvement in the frontal plane, transitional line angles, incisal embrasures and the three facial contours was required (Fig. 14). I thought her tooth color was acceptable so bleaching would not be necessary.

Orthodontics and microaesthetics
Fig. 14


The patient was treated with Pitts21 fixed appliances (OC Orthodontics) and an “active early” case management strategy. IPR was undertaken using the protocols outlined in this article, with refinement of both transitional line angles and incisal embrasures during treatment. Photography at each appointment documented the changes and allowed for planning further revisions.

The final results (Figs. 15 and 16) demonstrate how planning toward beautiful teeth and a beautiful smile helped achieve a wonderful transformation for the patient.
Orthodontics and microaesthetics
Fig. 15
Orthodontics and microaesthetics
Fig. 16


Conclusion
As orthodontists, we strive to achieve generous smiles for our patients. For years, we’ve focused on placing teeth in the right position relative to the face and underlying bone to get the best possible aesthetics and function, and I think we’ve done a pretty good job at that.

Now, with the techniques available and systematic approach to tooth recontouring (as suggested by Dr. Khayat), we also can set new aesthetic limits for our patients and ourselves. Achieving beautiful faces, beautiful smiles and beautiful teeth is within our grasp. We need only choose excellence.

References
1. Sarver, D. “Soft Tissue-Based Diagnosis and Treatment Planning.” Clinical Impressions, Vol. 14, No. 1 (2005), pp. 21–26.
2. Pitts, T. “Bracket Positioning for Smile Arch Protection.” JCO, March 2017, pp. 142–156.
3. Coachman, C. “How Would You Assess the State of Digital Smile Design?” Compendium, Nov/Dec 2021, Vol. 42, No. 10.
4. Pitts, T. “Begin With the End in Mind—and Finish With Beauty.” EJCO, Vol. 2, Issue 2, 2014, pp. 39–46.
5. Murthy, B. “Evaluation of the Natural Smile: Golden Proportion, RED or Golden Percentage.” J Consenery Dent, 2008 Jan-Mar 11(1), pp. 16–21.
6. Bansal, A. “Assessment of Association Between Tooth Morphology and Psychology.” Journal of Clinical and Diagnostic Research, Feb 2020, Vol. 14 (2), pp. 10–12.
7. Joiner, A. “A review of Tooth Colour and Whiteness.” Journal of Dentistry 365, 2008, pp. 52–57.
8. Sarver, D. “Enameloplasty and Esthetic Finishing in Orthodontics.” JERD Vol. 23, No. 5 (2011), pp. 296–302.
9. Duarte, M. “Morphological Simulation of Different Incisal Embrasures: Perceptions of Laypersons, Orthodontic Patients, General Dentists and Orthodontists.” JERD 2016.

Author Bio
Dr. Ilies Tibaoui Dr. Ilies Tibaoui is in private practice with his wife in Algiers, Algeria. He is also a member and instructor of the Pitts Master Program.

Because of the important roles management and communication play in orthodontics, Tibaoui is particularly interested in organizational and behavioral psychology.

He specializes in teaching aesthetics and beauty for orthodontists, the Pitts Protocol, blending extraradicular TADs with passive self-ligating brackets for complex cases, digital smile design, emotional dentistry and communication.


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