Smile of a patient

A fully facial analysis-based guide to edentulous treatment

Dr. Ernest S. Orphanos

To improve the predictability of our patients’ esthetics, treatment should be planned in a full facial context, not just that of oral anatomy. Without this consideration, even the most well-designed restoration risks disappointing esthetics.

CONTENTS

Anatomy of face and smile

Anatomy of face and smile

As dental professionals, our goal is to provide patients with both functional and esthetically pleasing smiles, particularly in cases where patients have lost all of their teeth. With this goal in mind, we conduct a thorough analysis of the patient’s facial anatomy, including assessments of various facial proportions such as the golden proportion, recurring esthetic dental proportion, and golden percentages.1 Incorporating all of these facial proportions is critical in determining the optimal size and shape of teeth and achieving optimal dentofacial esthetics. This analysis also serves as a diagnostic tool to help address challenges in achieving an ideal tooth position without dental landmarks.

Pre-operative assessment

A female patient with terminal dentition required full-arch restoration in both jaws. After cone beam scan and a periodontal and oral examination, she underwent an assessment of facial symmetry and proportions, including facial thirds, the proportion in the lower facial third, lip length, and lip mobility. Incorporating facial proportions is crucial for achieving ideal dentofacial esthetics and determining the anticipated incisal edge (AIE) position when planning for an esthetically pleasing smile. Ideally, the AIE position should show 1.0 to 2.0 mm at rest, with a repositioning of incisal edges apically by approximately 4.0 mm when smiling.

Pre-operative assessment

Periodontal examination and face analysis prior to surgery.

Surgical Protocol

The patient was treated with the All-on-4® concept in the mandible and full-arch on six implants in the maxilla. The maxillary ridge was reduced to ensure a minimum distance of 15.0 mm from the AIE, as determined from facial photos, to prevent the transition zone of the prosthesis from being visible during maximal smiling. Following alveolar reduction, a denture was fitted to evaluate proper facial support. After placement of implants, the patient received the provisional prostheses that produced a striking transformation in her appearance.

Patient's smile after delivery of provisional prostheses

After delivery of provisional prostheses.

Begin with the end in mind

The ultimate goal of full-arch treatment is to restore dental and facial esthetics, phonetics and function. An understanding of the facial anatomy can help clinicians determine optimal incisal position. This in turn can enhance the dental and facial outcomes.

Before

All images courtesy of Dr. Orphanos

After

References

1. Orphanos ES. Facial Esthetic Considerations with All-on-4: A Report on Two Cases. Int J Periodontics Restorative Dent. 2019;39(1):57-64. 
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