9 d1075 v_n_v_madhav

Journal of International Dental And Medical Research ISSN 1309-100X Esthetic Failures in Fixed Partial Dentures
http://www.ektodermaldisplazi.com/journal.htm Veu N.V.Madhav

ESTHETIC FAILURES IN FIXED PARTIAL DENTURES

V N V Madhav1*
1. Dr, M.D.S. (Prosthodontics), Reader, Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune, India.

Abstract

Esthetic dentistry encompasses those procedures designed to enhance and improve form and
appearance of the maxillofacial region. Esthetic dentistry procedures are performed on both hard
and soft tissue to correct either subjectively or objectively, patient perceived deformities.
Perceptions of esthetic deformities or needs are highly subjective. In this article an effort has
been made to outline the possible esthetic errors which occur in the absence of careful treatment
planning during the fabrication of fixed partial denture procedure.
(J Int Dent Med Res 2010; 3: (3), pp. 146-153 )

Keywords: Esthetic Failures, Shade Selection, Gingival Esthetics, Esthetic Smile.

Received date: 19 July 2010 Accept date: 21 September 2010

Introduction along with need for dedicated maintenance. The
proper selection of treatment occurs through a
The surge of interest in the use of tooth- comprehensive dialogue between the
colored restorative materials and systems in Prosthodontist and the patient in which both
recent years has been attributed partly to rapid subjective and objective evaluations are utilized
developments in dental materials science and to determine appropriateness of treatment and
also to patient demand and operator interest. thus enable the assumption; of reasonable risk /
When overall dental appearance is benefit ratio. The irreversibility of many esthetics
considered, several factors are of significance, procedures requires that the patient be fully
including tooth color, shape, and position; aware of future additional and / or alternative
restoration quality; and the general arrangement treatments if their initial esthetic goals are not
of the dentition, especially of the anterior teeth. met. In this article an effort has been made to
Each factor may be considered individually, but outline the possible esthetic errors which occur in
all components together act in concert to produce the absence of careful treatment planning during
the final esthetic effect. However, although the the fabrication of fixed partial denture procedure.
clinician must be mindful of the patient's desires
for a favorable cosmetic result, materials and Evolution of Ceramics as an Esthetic
techniques must be carefully selected, and Alternative
restorations should be sufficient to withstand the The metal-ceramic crown was introduced to the
forces of occlusion and mastication and provide profession over four decades ago. At the time
long-term function and esthetics1. there was tremendous excitement generated by
The elective nature of esthetic procedures the concept because it theoretically combined the
requires that the patient is thoroughly educated esthetics of the porcelain jacket crown with the
about possible risks and adverse consequences potential for clinical longevity2.
However, it is likely safe to state that most
clinicians were somewhat disappointed by the
*Corresponding author:
Dr. V.N.V.Madhav, M.D.S. (Prosthodontics)
initial clinical results obtained with this treatment
Reader, Department of Prosthodontics, modality. It is highly likely that most early esthetic
Bharati Vidyapeeth Dental College and Hospital, failures with metal-ceramic restorations were due
Pune . to a combination of errors in tooth preparation,
cervical margin design and soft-tissue
E-mail: vnvmadhav@yahoo.co.in management. Nevertheless, the disappointment
with metal-ceramic restorations was the genesis

Volume 3 · Number · 3 · 2010 Page 146


for the development of numerous all-ceramic  Midline error
alternatives to the metal-ceramic restoration. The  Imbalance of directions
past two decades has witnessed the  Artifact error
unprecedented introduction of alternatives to the  Diastema error
metal ceramic crown 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16.
In addition, many different techniques for Factors Affecting Esthetic Failures
fabrication of all-porcelain labial margins have One of the goals of any dental restoration
been developed to improve the inherent esthetic should be patient satisfaction. The restoration
performance of metal-ceramic restorations 17, 18, 19, should fulfill the requirements of correct
20, 21, 22
. In clinical situations with sufficient mastication function, appropriate morphology,
remaining enamel, etched porcelain laminate superficial staining, abrasion and other
veneers may also be considered to restore the characterization. Finally, the shade selected
teeth to both optimum esthetics and function 23, 24, must correspond to the individual, age related
25, 26
. appearance of the patient and should be identical
Thus, the contemporary host of indirect to the remaining natural teeth. Problems that
alternatives for the esthetic restoration of anterior arise during fabrication can be overcome in spite
teeth. It is also clear that ceramic technology has of the difficulty level, which varies from case to
matured to the point that it is possible to mimic case and depends in part on whether the
nature and provide restorations that defy restoration involves a single crown or a fixed
detection to even the trained observer. partial denture. A general requirement for the
success of laboratory work by the dentist (i.e.;
Classification of Esthetic Errors27; proper shade selection, correct tooth preparation
(Richard E. Lombardi; 1974) and final impression).
I. Inharmonious dento-facial ratio
1. Shade disharmony Tooth Shape
2. Compositional incompatibility The facial surface of the tooth is a part of
 Static prosthesis in dynamic mouth tooth form. It is decisive in shaping tooth's
 Inharmonious strength or weakness of appearance, particularly when severe changes
dental composition compared to occur in old age. The incisal edge, which may be
background features. slightly convex in shape initially, changes as well.
a. Weak mouth with strong face. As a consequence of abrasion it may
b. Strong mouth with weak face. eventually become concave. All of these variable
II. Intrinsic dental disharmony characteristics of tooth shape combine to
1. Space allocation errors determine the effect of the tooth in the mouth, to
 Inadequate vertical space allocation a significantly greater degree than does the
 Excessive vertical space allocation shade. The changes in the cervical region,
 Excessive horizontal space allocation through gingival recession for example, also lead
2. Structural line errors to an appearance typical of a certain age. These
 Elevated occlusal plane changes have a more pronounced effect on the
 Occlusal plane drops down posteriorly appearance of the dental arch than on the shade.
 Asymmetrical occlusal plane Because the gingiva usually recedes
3. Unnatural lines inter-proximally as well, it leaves the crown of the
 Reverse smiling line tooth with a more triangular appearance. If these
 Unnatural axial inclination teeth are replaced by a restoration having a
 Cusp less posterior teeth square form, they will appear more unnatural. It
is expected that the form of the clinical crown
 Gradation errors
correspond to the course of the root, which is
 Age-sex personality disharmony
often exposed because of periodontal disease.
4. Single-line errors
 Vertical deviation Surface Structure and
 Horizontal deviation Characterizations
 Line conflict The natural surface detail is most
5. Imbalance extensive in a young tooth. Many fine, detailed



irregularities occur, particularly on the labial To these three dimensions, and within the
surface. At the first glance one sees horizontal field of dentistry, we must add a fourth one which
depressions. Vertical lines become visible with would include all of the chromatic features that
more careful observation, so that a pattern of personalize the tooth apart from its average
very fine, slightly displaced rectangles is seen. color, and which are fundamental for the repro-
The older a tooth becomes, the less duction of the color of a tooth.
prominent these structure become. Millions of lip
movements in the same direction lead to Gingival Esthetics
formation of large smoothed regions between Factors Affecting Gingival Esthetics:
which few structured zones are retained. Enamel The morphology and dimension of supracrestal
tears, abrasions, discoloration, incisal edge periodontal tissues undoubtedly represent the
irregularities, bright spots, and band-shaped most important parameters to be taken into
shade variations are not the only consideration in designing a fixed prosthesis28.
characterizations that must be evaluated.
Cervical erosions and fine lines that The Esthetic Width; As the supracrestal
separate the clinical crown and the root, which connective tissue attachment is resected during
may result from simple aging or from oral tooth preparation, so should the esthetic width be
hygiene procedures, must also be evaluated. respected when designing the prosthetic
framework, a distinct space is necessary
Color between the coronal border of the gingiva and
Nature of Color: When we talk about the cervical margin of the framework to provide
color, we are making reference to a sensation adequate room for the application of specific
which is captured by our eyes. The human eye is shoulder porcelain.
an organ specialized in the reception of images
obtained from an electromagnetic radiation that The Umbrella Effect; A careful analysis of
we refer to as light, and which actually clinically relevant optical phenomena should
corresponds to a narrow segment of the entire always include the effect produced by the lips,
spectrum, situated between the 400 and 800 nm particularly the upper lip, because this feature will
wavelengths approximately, and which we significantly influence the interaction of light with
perceive as the so-called “colors of the rainbow”. the teeth and their supporting tissues. When the
Radiations below these wavelengths are lips are retracted, the apical extension of the
not visible to the human eye, and are referred to framework generally will not have a strong impact
as ultraviolet; those which are situated above on the optical behavior of the crown, because the
these wavelengths are not visible either, and are light can be directly distributed into the tissues.
referred to as infrared. When the upper lip is in its normal
There are generally three accepted position, however, the difference becomes
dimensions of color: significant, because direct penetration of light into
 Hue, tonality: this indicates the feature which the surrounding periodontal tissues is prevented.
is normally referred to as color, directly related In contrast, an adequately reduced framework
to the wavelength of the observed luminous does not demonstrate the so-called umbrella
radiation observed (e.g. red, green, blue, effect.
yellow…).
 Value, luminosity: this expresses the amount Esthetic Smile
of light that makes up the color under study, The smile is expressed by muscular
and would be like the black and white image action around the lips in the inferior third of the
of the observed object, corresponding to the face by a brightening of the eyes. The pleasing
tonalities of grey ranging from a maximum smile is one of our special forms of nonverbal
value, white, and a minimum value, black. communication, and it expresses joy.
 Chroma, saturation: this refers to the amount
of dye that the color contains, the chromatic The elements that effect in an esthetic
brightness that we observe. This dimension smile are;
refers to the different dilutions of the base  The upper lip position
color we are starting from.  The upper lip curvature



 The parallelism of the anterior incisal curve The property of light source to influence color of
with the lower lip objects is called “color rendition”. There are three
 The relationship between the maxillary main illuminants within any dental practice:
anterior teeth natural, incandescent and fluorescent.
 The number of teeth displayed in a smile Natural sunlight is itself variable with light
appearing blue at noon when the sun has fewer
The most attractive smiles have nearly atmospheres to penetrate and red/orange during
perfect harmony between the arcs of curvature of the morning and evening. Incandescent lighting
the incisal edges of the maxillary incisor and the is predominantly red/yellow and lacking in blue
upper border of the lower lip, and the upper lip while fluorescent lighting is high in blue tones
can be at the height of the gingival margin of the and low in red. There are special that are
maxillary central incisor. It was found that in an color corrected to emit light with a more uniform
attractive smile, the full shape of the maxillary distribution of color that can be utilized. Initial
anterior teeth was displayed between the upper shade selection should be initially made with be
and power lip. The upper lip curved upward or matched under different lights to avoid
was straight, the maxillary anterior incisal curve metamerism (the phenomenon that occurs when
was parallel to the lower lip, and the teeth were shades appear to match under one lighting
displayed to the first molar. condition and not another).

SHADE SELECTION FAILURES Factors Affecting Light Conditions
To date, there is no systematic training on  Gingival shade
visual shade determination 29, 30, 31 for dental  Influence of the surroundings
technicians or dentists32. Therefore; all attempts  Type and arrangement of the shade guide
to improve the color communication fail at this  Position of the shade tab
barrier.  Different color perception capacities
The many difficulties associated with  Knowledge about color and its perception
visual shade determination of manufactured or  Experience in shade selection
customized shade tabs for natural teeth are  Acting mechanism of the eye (simultaneous
further complicated by the fact that color contrast, contrast increase)
interpretation by the human eye is influenced by
a variety of factors. When determining a color, the human eye
Shade selection is an important perceives a certain shade; however, under
procedure to provide patients with an aesthetic modified light conditions, the color perception
restoration that harmoniously blends to the and the subsequent shade selection can be
patient’s existing dentition. Knowledge of the completely different. This implies that when
scientific basis of color from understanding light shade guides are used exclusively, the tooth
to also interpreting the artistic aspects of shade shade required is always described in an
selection ensures a successful result. Shade insufficient manner33-35.
selection involves the perception of color, which It is important to use auxiliary tools and a
depends on three entities: shade indicator that is arranged according to a
1. Light logical system oriented by the natural model
2. Object; and
3. Visual detection Object
The visual system of the eye is only Color possesses three dimensions: value,
capable of detecting wavelengths from 380 hue and chroma. A high value object often
(violet) to 780nm (red). Isaac Newton showed reflects most of the light falling on its surface and
that light had no color, as it is only when it appears bright. The converse is true with a dark
interacts with an object that color is produced. object absorbing most of the light and appearing
dull or of low value. Hue is wavelength of light,
Light and dependent on the spectral reflectance from
The color of an object can change an object. Chroma is the concentration of color or
depending on the illuminant, e.g. tungsten light color intensity
may cast a yellow color compared to daylight.


Visual detection preparation as teeth can become dehydrated
The third part of stimulus for color is the and result in higher values.
spectral response of the detector, or eye. The  Shades should be done when the dental team
difficulty of shade selection is that clinicians must is not fatigued as in the end of the day.
be able to interpret a multi-layered structure of  Ensure surgery surroundings are of neutral
varying thickness, opacities and optical surface color so that there is no color cast onto the
characteristics. This can affect the way that the teeth.
eye perceives color. The basic hue of the tooth is  Remove lipstick; ask patients not to wear lurid
determined by the color of the underlying dentine, clothing or any items that may distract the
while value is a quality of the enamel overlay. attention of the teeth.
Muia in 1993 stated, “The dentine imparts  Make sure teeth are clean and unstained
the entire color. Enamel is like a fiberoptic before attempting shade selection.
structure conducting light through its rods”.  Patient should be in an upright position at a
Chroma is the saturation of color in the level similar to the operator and the shade
dentine, but is influenced by the value and guide should be at arms length. This ensures
thickness of the enamel. Teeth are often termed that the most color sensitive part of the retina
“polychromatic” and have the variation in hue, will be used.
value and chroma within the teeth and give three  Observations should be made quickly (5
dimensional depth and characteristics. A young seconds) to avoid fatiguing the cones of the
dentition is characterized by opaque, high value eyes. If longer than this, the eye cannot
enamel, which blocks underlying dentine. As discriminate and the cones become sensitized
teeth age, the enamel becomes more translucent to complement the observed color.
and dull (low value) revealing the underlying  Blue fatigue can accentuate yellow sensitivity
dentine. This layering can make reading of tooth so dentists can look at a blue object, bib, etc,
color difficult since the value of enamel and while resting the eyes.
surface luster often complicate color evaluation
 Use color corrected light illumination, which
of the underlying dentine.
should be of a diffuse nature.
 Choose basic shade at the middle of the tooth
Contrast Effect
- using the Vita System 3D-Master technique
When a dental restoration is being
of value, chroma then hue. Viewing tabs
fabricated, the surroundings of the teeth,
through half-closed eyes can decrease ability
especially the shade of the gingival tissues, are
to discriminate color but increases the ability
decisive for the color integration of the restoration.
to match value. Look at the other parts of the
With the conventional visual shade determination,
teeth, dividing the teeth into nine sections
so-called simultaneous contrast effects and
from apical to incisal and mesial to distal.
contrast increases occur 36, 37, 38.
To explain briefly: Shade selection is  Necks of shade tabs often can be removed as
performed in a reddish environment-skin, lips, they have a great deal of colorants that may
and gingival tissues. This environment, and introduce errors.
especially the reddish-violet color of the gingival  Examine tooth for translucency and any
tissues, leads to a marked decrease in the characterizations, e.g. craze line,
receptiveness of this area to the color spectrum hyopcalcification, etc.
The brain replaces the apparent excess of red  Create a shade/chromatic map – divided into
with the complementary shades green to yellow. different sections to ensure correct placement
This leads to a subjectively modified color of different effects, characterizations and
perception, which expresses itself in a tendency shades.
toward seemingly objective yellowish shades.  In case of color blindness, seek the help of the
This contrasting effect can be neutralized by the assistant
use of a gingival mask.  Shade selection is done before tooth
preparation
Tips to Remember During Shade  Don't dry the tooth while selecting the shade
Selection Procedure  Moisten the shade tab
 Shade selection should be completed before  Canine is the darkest tooth



 Premolars are of lighter shade than canine failure, and thus increase the quality of
 For premolar select contra-lateral premolar restorations.
 When maxillary anteriors are missing, shade
of the mandibular anteriors are considered
 In case of a non-vital tooth, cover it and select
the shade of the adjacent tooth.
 Photograph teeth and tabs using different
lighting conditions to minimize metamerism,
e.g. flash (5500K) and natural daylight
(6500K). Table 1. Commercially Available Digital Shade
 Photograph teeth at 1:1 ratio for detailed Guides.
characterizations.
 Send digitized images and shade map to As a summary reasons for esthetic
ceramist. failures can be summarized as following.
 Failure to identify patient expectations
Stump shade selection regarding esthetics
With the increasing use of all-ceramic  Improper shade selection
restorations, it is important to communicate the  Failure to transfer the shade to dental
prepared tooth or “stump” shade to the ceramist laboratory
so that they can build the restoration with the
 Excessive metal thickness at incisal and
right opacity/translucency. It may be necessary
cervical region
as in to use a more opaque ceramic to block out
 Thick opaque layer application
discoloration, e.g. an alumina- or zirconia based
 Surface blistering ("chalky" appearance)
restoration may be a better choice than a glass-
based ceramic like Empress.  Over glazing or too much smooth surface
Although no single shade guide or  Metal exposure in connector, cervical and
combination of guides includes all of the color incisal regions
combinations that may be encountered in clinical  Dark space in cervical third due to improper
practice, a reasonably high level of clinical color pontic selection (Anteriors)
matching has been achieved, which attests to the  Failure to produce incisal and proximal
artistic skills of many dentists in selecting the translucency
best available shade and determining what color  Improper contouring
modifications are necessary to further enhance  Failure to harmonize contra-lateral tooth
the color match. morphology
1. Contour
Instrumental Shade Selection 2. Color
Given the great subjectivity that 3. Position
predominates all during the color measurement 4. Angulations
process in the clinic, a series of electronic  Discoloration of facing
instruments designed to facilitate and make more
objective the process of color measurement have The contemporary restorative dentist has
recently been appearing on the market. The a host of options with which to help his or her
practitioner thus needs only to use these devices patients are treated. Many of these options are
in order to be able to indicate the tooth’s color in considerably less invasive than many of our
a more precise, reliable and repeatable way. conventional restorative therapies. Many patients
Knowledge of the correct use of the present for esthetic restorative treatment, and are
conventional color measurement systems is becoming increasingly sophisticated in their
becoming more and more important if we wish to expectations of the final results. Additionally,
satisfy present day esthetic demands. manufacturers are bringing a myriad of new
This, together with the gradual entry and products to the market, often accompanied by a
perfection of the electronic color meter systems, blizzard of information purported to demonstrate
will serve to reduce the possibilities of aesthetic the benefits and efficacy of these new products.



Careful evaluation of patient’s expectations and 6. Cho GC, Donovan TE, Chee WWL. Rational use of contemporary
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Declaration of Interest 99–103.
27. Lombardi Richard E: a method for classification of errors in
dental esthetics. J Prosthet dent. 1974; 32: 501-513.
The authors report no conflict of interest 28. Malament Kenneth A: Periodontics and Prosthodontics. Goals
and the article is not funded or supported by any and objectives and clinical reality. J Prosthet dent. 1992; 67:
259-263.
research grant. 29. Egger B. Der Status quo der Ästhetik. Quintessenz Zahntech
1997; 23:191–204.
30. Preston JD. Der gegenwärtige Entwicklungsstand der
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