In this final installment of my 7 Violations of Smile Design series, I’ll explore how instituting a knowledge of gum symmetry, papilla heights, and smile lines can maximize positive outcomes in your esthetic cases. When evaluating the esthetic principles inherent to successful smile design, there are 7 violations that are common and undermine the success of the finished cosmetic case. Reviewing these commonalities and focusing on certain concepts such as gum symmetry can help you avoid and correct areas of concern.
Gum Symmetry – Overlooking Critical Positions
Everything begins with proper treatment planning. This is the basis for successful smile design and it is where you should focus your attention.
Clinical Tip #1: Properly evaluate the pink esthetics.
If you overlook the gingival margin positions, you’re leaving yourself vulnerable to the consequences of a treatment plan that under- or completely fails to utilize the gingival margins.
Ideal Symmetry Principles:
- The gingival margins of the canines and central incisors should be symmetric and in a more apical position compared to the gingival margins of the lateral incisors.
- There should be a gradual incisal movement of the gingival margins toward the more posterior teeth.
- The maxillary canines and central incisors should be on the same plane and the laterals should be in a slightly incisal position to that line.
Clinical Tip #2: The most important symmetry principle is to ensure that the gingival margins of the laterals fall short of the line drawn from the gingival apex of the centrals to the canines.
So when are these principles most integral in smile design? The answer is when treating patients with medium to high smile lines.
Elevate your knowledge with an understanding of the smile line. It is a labiodental dynamics principle that can be defined as the location of the lip when a person smiles.
Know the facts: 69% of people, when smiling, show 75% to 100% of their central incisors and inter proximal gingival papilla.
How can you utilize this knowledge? It all has to do with conceptualizing the advantages of symmetry versus harmony.
Gum Symmetry – Symmetry v. Harmony
It’s time to get back to basics.
Symmetry: The mirror image of parts of components about the y-axis.
Harmony: A recurring theme, such as having centrals or laterals of the same lengths.
Here’s where things get tricky and lean on the side of artistry, because the answer to whether you should emphasize symmetry or harmony in smile design might surprise you. From my experience, I can say that more emphasis should be placed on harmony over symmetry when designing a smile.
The key here is giving preferential treatment to balance and beauty over a form of unnatural symmetry.
Clinical Tip #3: Restored tooth lengths to create symmetry can disrupt the harmony of the smile, especially when gingival margins lack symmetry.
There are a lot of moving parts to consider, but what it comes down to is the unintended result of the smile creating an unpleasant appearance. My approach emphasizes a holistic sense of esthetic principles.
Clinical Tip #4: To resolve this issue and create harmony in the smile, ensure that tissue heights are evaluated in treatment planning.
Gum Symmetry – Plan for Success
One of my favorite methods for evaluating a smile line is to begin with excellent pre-treatment photography.
Clinical Tip #5: Gingival margins should always be evaluated with a picture/model that is properly oriented to resemble the patient’s horizontal position.
It really is all in the planning stages. Before you even being gingival contouring or hard tissue crown lengthening, go back to the drawing board and plan out gingival changes. Rely on information gathered from diagnostics, which can include sounding bone at various sites on each tooth.
Once again, you must emphasize planning. I cannot stress this enough. Without this crucial process, you may inadvertently create canted gingival margins or undesirable tissue heights.
Do not carry out surgical procedures without proper planning.
Clinical Tip #6: Create surgical guides or templates for the teeth.
These planning tools assist you in controlling gingival changes during surgery.
What it comes down to is an open and honest relationship with the patient, who can be an integral partner in the initial processes.
One way to take advantage of this is to evaluate images of the patient’s teeth and smile with the patient before performing any restorative treatment. This will help them visualize areas in the gums that are not ideal and could result in compromised esthetics.
Clinical Tip #7: Educate patients about their treatment prior to beginning treatment.
It may seem simple in hindsight, but in the end if you are not discussing compromises in a patient’s smile design with your patient, you will not be able to deal with any unrealistic expectations that they may have.
Check out the first six violations of smile design in the series, including “A Crooked Smile,” “The Reverse Smile,” “The Social Six,” “Four Central Incisors,” “Overcontoured Teeth,” and “Ignoring the Negative Space” to elevate your learning.