DTUS1210

f CT page 3C mation, has an inquiring mind, is highly exacting and emotional. This type is the most difficult to convince and takes the longest to reach a decision. Desire Desire is a subjective component. Increased public awareness of smile esthetics through the media has lead to a rapid increase in patients’ desires and levels of expectation. Patients are now willing to pay for the enhancement of their smile esthetics. Therefore, the ethical responsibil- ities of cosmetic dentists in identify- ing the need- or want-based desires of patients have also increased. The desires and levels of expectation in many patients are higher than what is clinically achievable, and it is the clinician’s duty to explain and guide patients towards a realistic esthetic goal. The psychological assessment of any person is very subjective; however, aspects like perception, personality, expectation or desire are important for the smile design procedure. Patient satisfaction is closely related to these aspects. Hence, understanding the pyramid of psy- chology is an integral aspect in smile design. Step No. 2: Establish the pyramid of health The pyramid of health is divided into three zones: general health, specific health and dento-gingival health. The health pyramid assess- ment and its management play a vital role in most cases, as patients may have certain limitations owing to their health, such as uncontrolled diabetes, soft-tissue pathology, poor bone structure, poor oral hygiene, tooth decay, periodontal disease etc., which should be addressed prior to functional and esthetic treatment. The health pyramid assessment process includes patient history (medical, dental, nutritional), exam- inations (extra-oral, intra-oral) and investigations (radiographs, pulp vitality test, study models analysis). Various types of questionnaires and clinical examination and inves- tigation protocols can be used to obtain the necessary information relating to the patient’s health. The clinician can use this infor- mation to prepare a personalised treatment protocol. All three com- ponents of the pyramid of health should be established within normal limits before starting any esthetic restorative procedure on a patient. Step No. 3: Restore the pyramid of function Function is related to force and movement. Hence, for the pyramid of function assessment, the exist- ing occlusion, comfort and phonet- ics are properly examined with the evaluation of para-functional habits, level of comfort during chewing and deglutition, and temporomandibular joint movement. The clarity of normal speech and pronunciation are also examined. The occlusion, comfort and phonet- ics components of the functional pyramid should be restored and maintained at an acceptable level before starting the treatment of any esthetic component. Step No. 4: Enhance the pyramid of esthetics The pyramid of esthetics is the last but most sensitive pyramid of the Smile Design Wheel, as esthetics has both subjective and objective aspects. The assessment of the sub- jective aspects — perception, per- sonality, desire — is carried out during the pyramid of psychology assessment. It is to be noted that the assessment of the objective aspects depends on the distance (focal length) used to visualise the esthetic component. Hence, the esthetics pyramid can broadly be divided into three major zones: macro, mini and micro. Macro-esthetics Macro-esthetics deals with the overall structure of the face and its relation to the smile (Fig. 6). To appreciate the macro-esthetic components of any smile, the visual macro-esthetics distance should be more than 5 feet. However, in clinical practice the assessment of the macro-esthetic components is done using various facial photographs with geometric and mathematical appraisals, using reference points and their interrela- tion. Various facial reference points and guidelines are used for esthet- ic assessment for orthognathic and facial cosmetic surgery; however, in smile design the following macro- esthetic guidelines are considered fundamental: facial midline; facial thirds; interpupillary line; naso-labi- al angle; and Rickett’s E-plane. Mini-esthetics Mini-esthetics deals with the esthet- ic correlation of the lips, teeth and gums at rest and in smile position (Fig. 7). The esthetic correlation can be appreciated properly when viewed at a closer distance than the visual macro-esthetics distance. The visual mini-esthetics dis- tance is similar to the across-the- table distance, which is normally within 2 to 5 feet. There are various guidelines in esthetics based on the relationship and ratio between lips, teeth and gingival tissue. These can be analysed during mini-esthetic assessment using frontal, vertical and transverse characteristics of the smile. Clinical photographs are the basic tools for mini-esthetic analy- sis. The smile can be analysed at rest (M-position) or smile (E-position). In the M-position, the following references are measured and anal- ysed: commissure height; philtrum height; and visibility of the maxillary incisors. In E-position the following refer- ences should be analysed: smile arc (line); dental midline; smile sym- metry; buccal corridor; display zone and teeth visibility; smile index; and lip line. Micro-esthetics Micro-esthetics deals with the fine structure of dental and gingival esthetics (Fig. 8). Mini-esthetics can be appreciated at a visual micro- esthetic distance of less than 2 feet or within normal make-up distance. For the clinical assessment of micro-esthetic components of the teeth and gingival tissue, appro- priate illumination and magnifica- tion tools are required for intra- oral examination. Necessary clinical intra-oral photographs should be taken for documentation and future reference. For micro-esthetics, the detail of the individual tooth structure and its relation to the surrounding gin- giva and the adjacent teeth should be analysed. The following are the major points to be considered: upper centrals (tooth size ratio); principle Clinical COSMETIC TRIBUNE | May 20104C Fig. 4 Fig. 5 Fig. 6 Fig. 7