The Finishing Touches by Dr. Trevor Nichols

Reshaping hard tissue to create a fantastic smile

by Dr. Trevor Nichols

• Uneven tooth length. Some people have teeth that appear uneven in length because of wear, genetics or other factors. Enameloplasty can gently reshape the edges of the teeth, creating a more symmetrical and balanced appearance.
• Minor chips or fractures. Small chips or fractures on the edges of teeth can be smoothed out through enameloplasty. This can improve the tooth’s appearance and prevent further damage to the enamel.
• Pointed or jagged teeth. Some people may have pointed or jagged teeth that can be uncomfortable or cause irritation to the lips, cheeks or tongue. Enameloplasty can round off these sharp edges, enhancing comfort and oral health.
• Correction of small irregularities. Enameloplasty can address small tooth imperfections in tooth shape, such as minor grooves, bulges or rough surfaces, that might bother someone.
• Harmony with facial features. Teeth that are disproportionately large or small in relation to other facial features can affect overall facial harmony. Enameloplasty can help create a more balanced and natural look by adjusting tooth proportions.
• A quick, noninvasive solution. Enameloplasty typically does not require anesthesia, and offers a simple solution for someone seeking minor improvements to their teeth without more extensive dental work and need for replacement later in life.
• Boosting self-confidence. Aesthetic concerns related to tooth shape can affect someone’s self-confidence. Enameloplasty can help improve self-esteem by addressing these concerns and creating a smile they’re proud to show.

1. Proportion and golden ratio. Dental artists often adhere to the golden ratio, a mathematical concept of proportion that’s been used in art and architecture for centuries. Applying this ratio to tooth dimensions can lead to a smile that’s perceived as balanced and attractive. For example, the width of a front tooth in relation to the tooth next to it can follow the golden ratio to create an aesthetically pleasing appearance.
2. Tooth length. The length of teeth is an essential consideration. Teeth that are too short or too long in relation to each other and the surrounding facial features can disrupt overall harmony. Dental artists take into account factors such as the size of the face, lips and gums to determine an appropriate tooth length that complements the patient’s features.
3. Tooth width and proportions. The width of teeth, especially in the anterior region, affects the appearance of a smile. Teeth that are too narrow or too wide can create an unbalanced look. Orthodontic artists consider the patient’s facial width, midline and the proportions of neighboring teeth to determine the ideal tooth width (Figs. 1 and 2).
4. Tooth contours and curvature. The contour or curvature of tooth surfaces contributes to the play of light and shadow, affecting how teeth reflect light. Orthodontic artists shape tooth surfaces to create a natural and dynamic appearance. For example, central incisors often have a more pronounced curvature, while lateral incisors may have softer contours.
5. Embrasures and contact points. Orthodontic artists carefully shape these areas to mimic the natural variations seen in healthy teeth. Properly designed embrasures and contact points create a lifelike appearance and prevent teeth from appearing too uniform.
6. Texture and surface anatomy. The texture of tooth surfaces is important for creating a realistic appearance. Teeth have subtle imperfections, fissures and variations in surface texture. Orthodontic artists re-create these details to make teeth look natural rather than overly polished or artificial.
7. Midline and incisal edge alignment. The midline, which is an imaginary vertical line that divides the face and the dental arch, should ideally align with the center of the face. The alignment of the incisal (biting) edges of front teeth also contributes to overall symmetry.
8. Individualization. No two teeth are exactly alike, and orthodontic artists take this into account when shaping teeth. Creating individualized tooth shapes that complement the patient’s unique facial features and personality is essential for achieving natural- looking results.
9. Cultural and gender considerations. Different cultures and genders often have distinct dental aesthetics. Orthodontic artists consider these cultural and gender norms when designing smiles to ensure the final result is in harmony with the patient’s background.
10. Patient input. Aesthetic dentistry is a collaborative process. Orthodontic artists work closely with patients to understand their preferences and expectations. Patient input guides decisions about tooth shape, ensuring the final outcome aligns with their desires.

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• Structural concerns. If a tooth has structural issues such as cracks, chips or deep fractures, enameloplasty may not be sufficient to address these problems. Veneers can offer both cosmetic enhancement and structural support.
• Irreversibility. Enameloplasty is a permanent procedure because once enamel is removed, it doesn’t naturally regenerate. While the amount of enamel removed is minimal, it’s important for patients to understand that the changes are irreversible.
• Ability to address discoloration. Enameloplasty cannot change the intrinsic color of a tooth. It can help remove surface stains, but can’t effectively address deep or severe tooth discoloration. Veneers, on the other hand, can provide a solution for both discoloration and shape changes.
• Natural tooth structure. Enameloplasty requires having enough healthy enamel to work with. If the tooth’s enamel layer is already thin because of wear, decay or previous dental work, further reshaping may not be recommended.
• Desire for comprehensive changes. If a patient is seeking comprehensive changes to their smile—alterations to tooth color, shape and size—veneers may offer a more versatile and comprehensive solution than enameloplasty alone.
• Patient expectations. Patients who have high expectations for a drastic transformation may not be fully satisfied with the limitations of enameloplasty. Veneers can offer a more noticeable and dramatic change in these cases when desired.

Product ordering list

• Fine diamond wheel bur
• Straight fine diamond chamfer bur
• Rubber-point polishing bur
• Coarse soft-flex disc
• Fine diamond soft-flex disc

Fig. 3

1. The flat, red fine diamond wheel bur is used to smooth lingual incisal and incisal edges of lower anteriors and round lower cuspids and bicuspids as needed (Fig. 4). This is done dry, and at a stall-out speed to not heat up the tooth or cause excess sensitivity.
2. The red fine diamond chamfer bur is then used on all facial surfaces (Figs. 5 and 6). This is also done at a stall-out speed and is used to flatten any facial enamel defects, white spot lesions or bulky areas of the tooth. This bur is used to parallel the long axis of the tooth and is also used at the same angulation from tooth to tooth to allow for proper flow. If a tooth is bulbous or appears to be flared, the bur can be used parallel to the adjacent teeth to improve the appearance of the tooth that appears to protrude from the arch form. This is done gently without overreducing the enamel, and done at a very slow speed to prevent scuffing of the enamel.
3. The black rubber-point tip is used on a high speed to polish the enamel on each tooth (Fig. 7). This is again done dry at a stallout speed. This bur will put an impressive shine on the enamel that will reflect light beautifully. This bur is used without pushing too hard on the enamel, and is used repeatedly until the tooth appears shiny.
4. The teeth are cleaned, mouth rinsed and verification is completed for Steps 1–3.
5. The incisal edges are revisited with the black soft-flex disc to ensure flat and even edges (Fig. 8). This is done carrying the flat portion of the disc from tooth to tooth, ensuring symmetry and flow from right to left. Many times, it is important to come in front of the patient to ensure the teeth are flat and symmetric from side to side.
6. Finally, the diamond-impregnated fine diamond disc is used for embrasures and lingual surfaces (Fig. 9). This is done with extra fulcrum and caution, because this disc can remove enamel easily. Embrasures are created, increasing in size from central to lateral, lateral to cuspid, etc. We look from all angles to remove any sharp edges or discrepancies.
7. Final photos are obtained and evaluated in the smiling patient photo. A black stick photo is also taken and inspected for needed changes.

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References
1. Sarver DM. “Enameloplasty and Esthetic Finishing in Orthodontics—Identification and Treatment of Microesthetic Features in Orthodontics Part 1.” J Esthet Restor Dent. 2011 Oct; 23(5):296–302.
2. Brandão RCB, Brandão LBC. “Finishing Procedures in Orthodontics: Dental Dimensions and Proportions (Microesthetics).” Dental Press J Orthod. 2013; 18(5):147–174.

Dr. Trevor Nichols attended Arizona State University, where he completed a bachelor’s degree in science and fitness and graduated as valedictorian. He then attended the Arizona School of Dentistry and Oral Health for his doctoral training, where he served as class president. While there, he also completed a certificate in dental public health. After obtaining his DMD, Nichols completed his specialty training in orthodontics at ASDOH and earned a master’s degree while completing research on TMD. He has also received inaugural awards in clinical excellence and leadership. Nichols is involved in organized orthodontics and as a lecturer educates other orthodontists and residents in the creation of beautiful, healthy, life-lasting smiles