Microaesthetics that transform
patient aesthetic outcomes
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
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.
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
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
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
- 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
Figs. 2a and 2b: Short teeth corrected by positive coronoplasty.
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:
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-
- Alteration in tooth position
(VID/VIP, gingival display,
- Changes in white (tooth)
- Changes in pink (gingival)
Given the constraints of space, this article
will be limited to developing whitetissue
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
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.
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.
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
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.
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.
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).
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
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
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.
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.
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.
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.
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
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
The final results (Figs. 15 and 16)
demonstrate how planning toward beautiful
teeth and a beautiful smile helped
achieve a wonderful transformation for the
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
1. Sarver, D. “Soft Tissue-Based Diagnosis and Treatment
Planning.” Clinical Impressions, Vol. 14, No. 1 (2005), pp.
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.
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.
Dr. Ilies Tibaoui is in
private practice with his
wife in Algiers, Algeria.
He is also a member and
instructor of the Pitts
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.