Recommended clinical practice guidelines of aesthetic dentistry for Indians: An expert consensus

Abstract

Objective:

The research for analyzing the smile characteristics in the Indian population has been limited with contradictory outcomes. This consensus statement aims to critically review the literature and provide basic practice guidelines on dental aesthetics related to the Indian population.

Clinical Considerations:

9 clinicians and 6 resource persons from dental colleges in India collaborated in this consensus statement which covered 6 topics along with 6 introductory and 6 conclusive remarks. The statement was developed through a colloquium conducted on topics; global aesthetics: different smile design proportions and guidelines, patient perspective towards aesthetic dentistry in India, a literature survey of aesthetic dentistry for the Indian population, macro and micro-aesthetics, multidisciplinary approach in aesthetic dentistry, inclusion of high-end technologies in Indian modern-day practice, followed by a panel discussion to devise and establish the practice guidelines of aesthetic dentistry in India. The Consensus Statement has been formulated according to AGREE Reporting checklist.

Conclusion:

The experts and panelists reached a Consensus on protocols to institute clinical practice guidelines of aesthetic dentistry for Indians. However, based on all available literature from India, further research is required to investigate many questions that have not been previously considered.

INTRODUCTION

Every individual is born with a unique personality, and so is the smile. As rightly said, “Beauty in things exists in the mind which contemplates them” (David Hume). Each mind perceives beauty differently, and so are the cultures and ethnic backgrounds.[1]

The smile is an important component in a person's appearance, favoring his or her social acceptability. Esthetic dentistry plays an important role in enhancing a patient's smile, and a thorough, systematic dentofacial examination is required before commencing any esthetic procedure. Numerous elements, such as socioeconomic, regional, and cultural variances, may considerably affect facial sthetics perception.[2] However, the number of researches performed to analyze smile characteristics in the Indian population has been limited, with conflicting outcomes. This consensus was conducted to critically review the literature on dental esthetics related to the Indian population.

Different guidelines for esthetic dentistry are available globally. These guidelines or concepts determine whether a smile is appealing, ordinary, or unattractive. Smile and confidence can be significantly compromised if these key principles of smile design are violated by nature, yourself, or your dentist.[3] However, the global area has a significant impact on esthetics. Since there are no guidelines available in the literature for the Indian population, this consensus aimed to establish principles of esthetic dentistry and customize an innovative protocol for the Indian population.

Following a colloquium and panel discussion with resource individuals and panelists from the different parts of India, the consensus statement was drafted.

What are the existing proportions and guidelines for conducting esthetic dentistry clinical practice?

Dimension of teeth is important during esthetic treatment planning to achieve a balanced and pleasing smile. Various theories have been postulated to describe the proportional widths of the maxillary anterior teeth [Table 1]. Bhuvaneswaran compiled the principles on how to create a harmonized smile based on the available literature. This includes the integrated analysis of facial and dental structure.[3]

Table 1.

Different smile design proportions in dental esthetics

Smile design proportions	Description	Proposed by
Golden proportion	Each anterior tooth is 60% the breadth of the neighboring tooth when viewed from the front. (the mathematical ratio being 1.6:1:0.6)	Lombardi, 1973[4]
	Intercanine width in golden proportion to commissural width	Rufenacht cr. 1990
Golden rectangle of central incisors	Height of the central incisor/width of the two central incisors 1.6/1	Dr. Stephen Marquardt, 1988
Golden percentage	The proportional width of each tooth should be: canine 10%, lateral 15%, central 25%, central 25%, lateral 15%, and canine 10% of the total distance across the anterior segment	Snow, 1999[5]
Golden standard	The width of an anterior tooth should be 80% of its height	Wolfart et al., 2006[6]
Preston proportion	Width of maxillary lateral incisor=66% width of central Incisor, width of canine=84% width of lateral incisor	Preston, 1993[7]
RED proportion	The proportion of the successive width of the teeth remaining constant when progressing distally from the midline	Ward, 2001[8]
M proportions	Compares the tooth width with the facial width using a software	Methot, 2006[9]
Chu’s esthetic gauges	Range and mean distribution frequency of individual tooth width of the maxillary anterior dentition (based on Levin’s RED concept)	Chu, 2007[10]
Calculation of width of anterior teeth Segment based on several anatomical measurements	Interzygomatic width/3.3=intercanine width	House and loop, 1937
	DDC (distance between distal surfaces of maxillary canines)=1.305×IAD (IAD, measured in digital photographs)	Gomes et al. 2009[11]
TR proportion	Mesiodistal width of canine/sum of mesiodistal width of anterior teeth=0.3 The sum of mesiodistal width of central and lateral incisor/sum of mesiodistal width of central and lateral incisor=0.6	Shyagali et al. 2021[12]

RED: Recurring esthetic dental, TR: Tarulatha-Ruchi proportion, IAD: Interalar distance, DDC: Distance between distal surfaces of maxillary canines

However, these proportions and principles vary regionally and in people of different ethnicity. Hence, their relevance needs to be determined while designing smiles in different parts of the world.

Do various proportions match a beautiful-looking smile?

There were no studies that found evidence supporting the adoption of a single mathematical formula to predict cosmetic success. Recently, a systematic review done by MA et al.; concluded that tooth proportion varies substantially. There are no mathematical data or formula which can be used to predict consistent esthetic success.[13] The golden proportion has its limitations, i.e., both incisors (central and lateral incisor) are in a golden proportion, though this is not true for lateral incisor and canine. However, the golden percentage could be considered as a preliminary step if it is adjusted in every case.

What is the patient perspective toward esthetics clinical dentistry in India?

Beauty perception changes in the Indian population from south to north, and from east to west due to wide cultural background. Hence, only one guideline cannot be applied to the entire Indian population. As a matter of fact, Indians consider a small diastema in between their teeth to be auspicious! They welcome luck with facial asymmetry more than golden proportion. However, all individuals are trained to look upon white skin and similarly bright white teeth.

The optical qualities of the tooth structure were regarded as potentially essential among the dental parameters. A bright color of teeth was said to be a major characteristic of harmonious physical characteristics. According to several researches, there are discrepancies in the perception of appropriate dental shade among patients and professionals[14] and between participants of various ages,[15] with younger female respondents exhibiting a definite preference for whiter teeth. In developed countries, the number of patients interested in improving their teeth color has increased. There are limited statistical data on the importance of dental esthetics in general, and especially dental color in the Indian population, which has been published. A recent study conducted by Mahajan et al. among the Indian population concluded that the patients primarily preferred the lighter shades with high values.[16]

Oral health does not mean the absence of oral diseases. It includes a functionally stable and esthetically pleasing structure. It has a vital role in developing dentofacial self-confidence and, hence, influences social life. There is a huge difference in perception between a dentist and a patient. The dentist should be aware that even when patients are sensitive to detrimental aspects of their smiles, they are not willing to undergo treatment to improve them.

How to evaluate patients’ attitudes toward esthetic dentistry in the Indian population?

Few studies are available in the literature on the techniques of evaluation of patients’ perspectives toward esthetic dentistry. For instance, the PIDAQ questionnaire gives an idea about oral health-related quality of life by quantifying esthetic concern psychological and social impact.[17]

In addition, Rhee has developed an objective scale named “Balanced Angular and Proportional Analysis” (BAPA) to quantify the esthetic characteristics of different ethnic groups.[18] This scale measures ethnic, racial, and gender differences regardless of generation and time. However, there is a poor correlation between subjective scale (visual analog scale) and objective scale (BAPA). Hence, it can be concluded that the golden proportion might not be attractive to human eyes.

The Dental Esthetic Index Scale determines optimum oral health, including occlusal harmony and pleasing dental esthetics. This index classifies esthetic dental treatment as “want-based treatment” and “need-based treatment.“[19] Need-based dentistry is practiced when a person has significant dental issues that must be corrected as soon as possible. Whereas want-based dentistry is performed when the person's oral health is not affected critically, one still wants to undertake some dental procedures to improve the overall appearance.

Current literature on esthetic dentistry clinical practice in the Indian population

Modern India stands as one of the most diverse countries in the world, so it is difficult to generalize the conclusions for the country as a whole. Several studies related to esthetics have been conducted partwise to analyze multiple factors important for dental esthetics. However, the amount of research undertaken to assess smile parameters in the Indian population is limited, with mixed results. A literature search was carried out in 3 electronic databases (PubMed, Scopus, Web of Science), and studies were eligible for inclusion if they assessed the factors related to dental esthetics and were performed specifically for the Indian population. A standard has been formulated in an esthetic smile relative to the smiling type: high, average, and low; teeth visibility while smiling, maxillary incisal curve parallelism with the lower lip. Golden Proportion is a mathematical element of design that the dentist should be aware of. Other crucial parameters include buccal corridor, the coincidence of the dental midline and the facial midline, gingival display, maxillary incisor exposure (MIE), smile index, most posterior maxillary tooth visible, smile arc, buccal corridor ratio, the anterior height of the smile, posterior height of the smile.

INDIAN STUDIES

The Indian Studies have been grouped under separate categories as depicted in Table 2, which shows the bias of; Gender, sample size and population inclusion restricted to one city.

Table 2.

Literature survey of esthetic dentistry for the Indian population

Authors, year	Geographic population	Sample size	Age group (years)	Parameters evaluated	Study type	Method	Data analysis	Results	Bias
a. Esthetic parameters with ocular landmarks
George and Bhat 2010[20]	South India	300	18-26	To evaluate If ICD* and CIW* were in golden proportion in south Indians To compare the mean CIW and ICD between males and females Comparison between south Indian and Arabian populations	Cross-sectional	Manually; with a digital vernier caliper	Z test, pearson’s correlation	ICD and CIW are in golden proportion ICD was a reliable predictor of maxillary CIW when multiplied by a declining function value of geometric progression term 0.618 and divided by 2 Males had considerably higher maxillary CIW and ICD than females When compared to the Arabian population, both ICD and CIW were greater in the south Indian population	Gender (female >male)
Grover et al. 2017[21]	North India	100	18-25	To analyze Incisal plane parallelism with interpupillary line Presence of a mismatch between the midline of the teeth and the midline of the face Maxillary anterior incisal curve parallelism with the lower lip Gingival display in a social (posed) smile	Cross-sectional	Standardized photographic procedure; digimizer image analysis software	Descriptive, spearman correlation test	The majority of individuals had an incisal plane and interpupillary line parallelism>half of the students had their facial midline and arch midline coincide Mostly parallel or straight smiles were present The amount of gingival display was comparatively less common	Small sample size limited to one age group
b. Sexual dimorphism
Balani et al. 2014[22]	Central India	100	13-16	To establish static norms for smile parameters: MIE, smile index, most posterior maxillary tooth visible, smile arc, buccal corridor ratio, anterior height of smile, posterior height of the smile To analyze sexual dimorphism in several components of an esthetic smile	Cross-sectional	Standardized photographic procedure; adobe Photoshop 7.0.1 software	Unpaired t-test, Chi-square test	Sexual dimorphism is seen; low-smile lines are primarily a male trait (2.5:1; Male: Female), and high-smile lines are primarily a female trait (2:1; Female: Male) Females tended to have a parallel smile arc, but males tended to have a flat smile arc Girls exhibited second premolars more frequently than boys, who exhibited first premolars The medium-type buccal corridor was the most common Girls display higher anterior and posterior smile height than boys Average posterior smile height was slightly more common Males showed mostly Low posterior height smile than females The statistically significant difference in terms of sexual dimorphism with an average smile reveals 75-100% of maxillary incisor height	Selection (small sample size, limited to one age group)
c. Soft tissues in an esthetic smile
Nichani et al. 2016[23]	South India (Bangalore)	100	20-25	To define shapes of maxillary central incisors and evaluate their relationship with the visual appearance of interdental papillae while smiling	Cross-sectional	Digital photography	-	Women showed a higher percentage of papillary display compared with men	Small age range
Ganji et al. 2018[24]	Saudi, Indian, and Bangladesh	114	20-30	To measure the gingival zenith width in convex, concave, and straight face profiles quantitatively	Cross-sectional	GZP on the maxillary upper right and left central incisors evaluated on scanned dental plaster model using CBCT	One-way ANOVA test	When comparing GZP in different facial profiles, a statistically significant difference was found For convex profiles, the mean distance of GZP and VBM of #21 was higher than #11, whereas, for concave and straight profiles, the mean distance of GZP and VBM of #21 was higher than #11 Emphasizes the importance of facial profile in smile design during restorative and prosthetic procedures	Gender (only on male population)
Sethna et al. 2019[25]	South- western (Mumbai)	150	18-25	Objective smile analysis based on gingival visibility during natural smile and posed smile Relationship between upper lip length and the smile line	Cross-sectional	Standardized photographic procedure Digital vernier callipers	χ2 ANOVA t-test	Natural smile  Maximum patients had a Low smile line; females- most frequent was High smile line males-most frequent was Low smile line Posed smile  Low smile line for both females and males  The statistically significant difference between smile line classes and upper lip length at rest (P<0.05)  Low smile line had highest lip length and vice versa	Gender (female >male)
d. Questionnaire-based studies
Manipal et al. 2014[26]	South (Chennai)	100	18-27	To determine awareness of dental esthetics in dental students	Questionnaire survey	19 questions with five aspects: Physical, functional, social, knowledge, and psychological	Chi-square test	Physical: Pigmentation shows more significance; students seek treatment for their pigmentation of the lips and gums Functional: Eating, as students have difficulty while eating Social: Habits; as it affects their esthetics Psychological: Mental depression; as students feel more deprived as a result of their unesthetic appearance	Selection (limited to one city)
Vinita 2020[27]	South (Chennai)	462	15-35	To evaluate the knowledge and awareness of teeth whitening among young adults	Questionnaire survey	Self-administered questionnaire	Chi-square test	73.4% of participants were affirmed that they knew about teeth whitening 62.1% were affirmed that their self-confidence and self-esteem were influenced by tooth color 68.4% of participants agreed that smoking leads to tooth staining 65.4% agreed: Maintaining the tooth color was related to oral hygiene 67.3% of participants asserted that brushing hard cannot whiten their teeth 68.6% preferred consulting dentists, while 31.4% (145) advocated home remedies for teeth whitening Emphasizes the concern young adults have about their tooth color; with dental esthetics having a stronger influence on psychological well-being	Selection (limited to one city)
e. Tooth color in esthetic dentistry
Kuckreja et al. 2017[28]	North	117	18-24	To measure the tooth colors in the North Indian population	-	With a digital colorimeter, VITA Easyshade®advance 4.0.	-	The most common shade in the cervical third was 1M2, followed by 1M1 in the middle third and 2M1 in the incisal third From cervical to incisal, the value rises M is the most common color in the yellow-red range of natural tooth tints, which includes L (yellow) and R (red) From cervical to incisal, the chroma is within a factor of two	(Small sample size, limited to one age group)
f. Proportions in esthetic dentistry
Meshramkar et al. 2013[29]	South (Dharwad, Karnataka)	214	18-25	To find out how common the ‘golden proportion and recurring esthetic dental proportion’ are in people with attractive smiles	Cross-sectional	Digital photography and digital analysis	-	The RED proportion was present in 6.6% of the population as opposed to the golden proportion which was found in 0.6% of the population	Age group
Agrawal et al. 2016[30]	West India (Gujarat)	80	20-23	To examine the existence of the golden proportion, RED proportion, and a golden percentage between the frontal view widths of the maxillary anterior natural teeth in Indian pupils	Cross-sectional	Digital photography and software	-	The golden proportion and RED proportion were not observed in the natural smiles of subjects who were deemed to have an esthetic smile	The small range of age group
Shetty et al. 2017[31]	Indian population (in UK)	100	18-35	Analyze anterior tooth dimensions, proportions, and relationships	Cross-sectional	Stone casts and vernier caliper	A paired and independent- sample t-test	Significant differences in length of upper left central incisor and upper right and left canines between male and female subjects (P<0.05) Significant differences (<0.05) in width to length ratios between right and left canines No golden proportion associations are to be found	Not representative of all Indian people living in the UK, let alone elsewhere in the world
Lavanya et al. 2021[32]	South (Telangana)	60	18-30	To determine which proportional formula (golden proportion, golden mean, and the preston proportion) exists in the local population	Cross-sectional	Plaster casts and digital vernier calipers	ANOVA	The formula of golden proportion and golden mean had no statistical differences between males and females - and is recommended during esthetic rehabilitation. However, the preston proportion has shown statistical differences in the total population
Singh et al. 2011[33]	North India	70	-	To investigate the existence of this ratio among individuals with natural dentition and to validate its role in esthetic oral rehabilitation	Cross-sectional	-	Eighty percent of the subjects varied within 2 standard deviations of the ratio of 1.618 The golden rectangle was found to have a significant relationship with the esthetic appearance of maxillary central incisors	Small sample size
g. Studies correlating central incisor and face form
Mehndiratta et al. 2019 [34]	South India (Belagavi)	200	18-30	To identify the relationship between the shape of the face and the different types of MCI	Descriptive	Photography and AutoCAD	χ 2	The most prevalent tooth form in both men and women was ovoid, and the least prevalent was square The association between face shape and tooth form was not significant	South Indian population
Koralakunte and Budihal 2012[35]	South India (Davangere)	200	18-28	To evaluate the relationship between the shape of the MCI incisor tooth and the shape of the face	Descriptive	Photography	χ 2	No highly defined correlation between maxillary central incisor tooth form and face form	Female bias 121 versus 79

MIE: Maxillary incisor exposure, RED: Recurring esthetic dental, MCI: Maxillary central incisors, CAD: Computer-aided design, GZP: Gingival Zenith Position, CBCT: Cone Beam Computed Tomography, ICD: Inner Canthal Width, CIW: Width of maxillary central Incisor, VBM: Vertical Bisected Midline

How to conduct an aesthetic treatment, and what are the Macro-esthetic and Micro-esthetic clinical practice guidelines for the Indian population?

1. Data acquisition

   1. Clinical radiographs and oral prophylaxis

   2. Study models/intraoral scan

   3. Preoperative/baseline photographs.

2. Patient interviews

   1. Patient's expectations to ideal smile. Patient's own drawings about desired smile

   2. To find patients temperament/psychology

   3. Video recording of the interview

   4. Eesthetic preevaluative temporary (without golden proportion, according to the desire of the patient)

   5. Evaluation of the intraoral mock-up (first five seconds).

3. Creative designs

   1. Esthetic/functional/structural/biological evaluation

   2. Inclusion of ceramist's views

   3. Meeting with spouse/parents

   4. Final decision making.

4. Treatment executions

   1. Selection of materials

      Factors to be considered

   2. Selection of method (direct/indirect).

Data acquisition

Clinical radiographs and oral prophylaxis

A thorough diagnosis is paramount to understanding the patient's needs. Diagnostic aids should include a complete set of intraoral periapical radiographs. It is important to evaluate the teeth radiographically to rule out any need for endodontic treatment or replacement of existing restoration.

Oral prophylaxis is important to match the exact shade and to achieve predictable bonding.

Study models/intraoral scan

Facebow-mounted diagnostic models and intraoral scans are to be done to acquire the baseline characteristics of existing dentition, shade, shape.

Preoperative photographs

Intra-oral and extra-oral photographs, the frontal, both lateral, and intraoral views, are important, which will help in effective communication to the laboratory.

Patient's interview

Patients desires and expectations of the smile

The patient should be the co-creator of the smile and not just the mere recipient of the treatment plan. Through the discussion with the patient, an operator must understand the patient's idea of a beautiful smile. The video recording of this appointment will help in records of the dental office and aid the dental clinician in observing the casual/formal/social smile of the patient.

Gathering the knowledge about the patient's desires should be the starting point of this appointment to directing the patient to understand what displeases him/her about the existing smile or the facial esthetic harmony.

Active listening to the patient's desires is a key to achieve this. It is essential to know the patient's idea of a beautiful smile before educating him/her further on various available treatment options. Effective education during this appointment often precipitates a shift in the patient's inclinations toward the smile makeover. An important aspect is what the patient has presented with as his chief concern regarding smile esthetics, i.e., whether a single specific defect is bothering the patient or the overall appearance of the smile as a whole. A patient's esthetic awareness and concern play an important role. Patients with lower esthetic awareness are usually concerned with functional defects and choose to correct them. Whereas patients with an average awareness are more interested in correcting a deformity such that it blends harmoniously with the facial features.

To find patients temperament/psychology

Understanding the patient's temperament / psychology, self-image plays a pivotal role in treatment acceptance and success of the esthetic treatment.

Good communication encourages the patients to take active participation in their treatment. The self-aware patients are seen to be more compliant with the treatment plan. They usually take mutual responsibility in the execution of esthetic care.

Video recording of the appointment

This will help not only in the dental office records but also aid the clinician and the lab technician in understanding the patient's social/formal and casual smile.

Esthetic preevaluative temporary (without golden proportion, according to patient psychology)

This should be based essentially on the patient's assumption of what would be a beautiful smile. No mathematical proportions are to be applied for the conventional temporary, but only the patient's ideas are to be incorporated without any bias. At this appointment, an esthetic treatment should be planned without bias toward a direct or indirect approach.

Intraoral evaluation

Esthetic pre-evaluative temporary should agree with the patient's ideas, which can be further used as a template for verifying the functional as well as phonetics requirements. The laboratory mock-up can be verified by transferring it intra-orally. The initial response of the patient in the first 5 s is unbiased, and without rationalizing the results thus, that should be taken into consideration.

Creative designs

Esthetic/functional/structural/biological evaluation

Through a comprehensive examination of the prepared mock-up, a combination of functional, structural, biological compatibility with the patient's esthetic desires is determined.

Inclusion of ceramist's views (in case of indirect restorations)

In this appointment, various esthetic treatment options that are compatible with the patient's esthetic desires should be discussed concerning functional, structural, and biological considerations in the presence of a ceramist. Communication is fundamental for the successful outcome of an esthetic case. One of the most crucial aspects of esthetic treatment is to make sure that the patient is well aware of treatment options and outcomes. Another important aspect is ceramist should be well aware of the patient's demands or perception of the ideal smile.

Meeting with spouse/parents

This meeting can include the spouse, parent, or anybody else who may be engaged in the decision-making process.

Final decision making

The patient's disappointment is often seen due to miscommunication or misunderstanding about the treatment outcome and not the actual treatment error. Each stage of treatment, i.e., diagnosis, treatment planning, and provisionalization, an agreement between dentist-patient and the dentist-lab technician that focuses on the functional and esthetic goals can ensure predictable success.[36,37,38,39]

Treatment executions

While planning an esthetic treatment, it is paramount for a clinician to understand the beauty, harmony, proportion, and balance perceived by that ethnic population. The most important factors are the size, shape, and arrangement of the maxillary anterior teeth, particularly the maxillary central incisor. We propose clinicians can design a smile that merges with the patient's facial appearance with his personality and esthetic desires.[40]

Hippocrates put forwarded a concept wherein a person can have four variations of temperament or a combination of two or more than two viz. choleric, sanguine, melancholic, and phlegmatic. The term choleric can be correlated with strong, sanguine with dynamic, melancholic with sensitive, and phlegmatic with peaceful. It is nothing but “Visagism.” It is a novel concept. It applies the principles of visual art to the composition of a customized smile. This concept allows clinicians to design a smile that blends the patient's personality, desires, and physical appearance. The divisions of smile esthetics advocated are the micro-esthetics of the teeth and macro-esthetics–smile.[41,42]

The micro-esthetic– teeth: the parameters include:

1. The long axes of central incisors

2. The shape of the central incisor

3. The connectors (the connection line of embrasures).

The concept of the shape of the face and teeth in relation to the four temperaments associated with the type of personality presumes a harmonious relationship between smile design and the patient identity. However, the challenging part about this is the lack of an objective method of assessing the personality of the patient and incorporating it meaningfully in smile design. The shape of the face and teeth in relation to the four temperaments associated with the type of personality of the patient can be described as follows.

The patients with choleric/strong temperament present with strong leadership qualities, fearlessness with rectangular faces with well-defined angles.

The long axes of central incisors are best-suited perpendicular to the horizontal plane.

The rectangular shape of the central incisors is best suited with a horizontal connection line of embrasures.

The individuals with sanguine/dynamic temperament present as active, outspoken, and extroverted with an angular face.

The long axis of the central incisor is best suited inclined slightly distally to the horizontal plane.

The triangular or trapezoidal shape of the central incisors is best suited with embrasures ascendant from the medial line.

The individuals with melancholic/sensitive temperaments present as gentle and abstract thinkers with an oval face and rounded features.

The long axes of central incisors are best suited inclined distally to horizontal plane with oval shape and embrasures descendent from the medial line.

Phlegmatic/peaceful temperament individuals present with gentle, discreet, and diplomatic with round or a square face, the long axes of the central incisors are best-suited perpendicular to the horizontal plane with small square-shaped central incisors and straight embrasures.

The macro-esthetic parameters of the smile.

When an individual tooth is denoted as a single unit and contributes to esthetics, they are then considered as macro esthetics. It evaluates the relationships of anterior teeth to each other as well as with their surrounding soft tissues. The following parameters can be considered in Macro-esthetics. Smile mobility, Smile arc, Lip fullness, Buccal corridor, Gingival display, Crown height, Crown width.[43]

What is the role of a multidisciplinary approach in esthetic dentistry clinical practice?

The increased acknowledgment of esthetics by the general population has prompted dentists to examine esthetics in a more organized and methodical manner. Esthetics encompasses not only the enhancement of one's smile but also the improvement of facial profile and jaw. Thus, without the help of multiple other dental specialties, few dentitions cannot be re-established to a more appealing appearance.[44]

• Conservative dentistry and endodontics: conservative dentistry and endodontics are concerned with the treatment of diseases and defects of the hard tissues of the teeth, with a focus on the restoration of their form, function, and esthetics

  1. Correction of the color of the teeth: Tooth discoloration is one of the commonly encountered complaints a dentist comes across. Such discoloration could be because of extrinsic or intrinsic staining. The treatment options vary from much conservative bleaching (vital and nonvital) to abrasion (micro and macro abrasion) and prosthesis (veneers, crowns). Nonvital tooth requires endodontic treatment before color correction[45]

  2. Space closure: Though space closure is primarily done by orthodontic treatment, small spaces can also be closed via restorative procedures. With the advent of tooth-colored restorative material and minimal to no preparation techniques, these procedures often provide a faster and more conservative approach[46]

  3. Change in shape and contour of the teeth: Various cases require alteration in the shape and contour of the teeth. Such correction can be done without any preparation to minimal or extensive preparation based on the extent of change demanded. The treatment options can range from minor restorative procedures to veneer and crown placement[47]

  4. Change in size of the tooth: Restorative procedures can also be used to alter the size of the teeth. With the advent of pink composites, it is now possible to mimic the gingival, giving it a life-like appearance. Pink composites can even be used to replace the missing papilla[48]

  5. Correction of malalignment: Though orthodontic treatment is the choice to correct malocclusion, few cases that require mild alteration in the alignment can also be corrected using the restorative procedure.[49]

• Periodontics: Periodontal therapy is concerned with improving periodontal health and maintaining the attachment apparatus’ integrity

  1. Crown lengthening: Crown lengthening is a surgical procedure that requires the removal of hard and soft periodontal tissues to obtain the supracrestal length of the tooth, keeping into consideration the biological width[50]

  2. Correction of the gummy smile: A gummy smile can be caused by one of two issues: altered passive eruption or maxillary excess in the vertical dimension, or both. The gummy smile is most likely caused by altered passive eruption if teeth appear short and squat-the vertical dimension seems abnormally small in comparison to the horizontal dimensions. On the other hand, if there is an expanse of tissue below the inferior border of the upper lip with an outline of the tooth appearing normal, it is most likely because of vertical maxillary excess or overgrowth of the maxilla[51,52]

  3. Frenum correction: The maxillary frenum can sometimes jeopardize gingival health, cause cosmetic issues or affect the orthodontic results. Frenotomy and frenectomy can be done separately as localized treatments or in combination with other procedures to expand the gingival attachment zone[53]

  4. Interdental papilla reconstruction: The true reconstruction of interdental papilla uses free connective grafts being placed between the full-thickness flap and alveolar bone or between the connective tissue of partial-thickness flap

  5. Gingival depigmentation: Various treatment modalities like surgical intervention (gingival abrasion technique, split-thickness epithelial excision, or combination), cryotherapy, and LASERS are widely used depending upon the extent of pigmentation.[54]

• Orthodontics: Orthodontic esthetics encompasses micro and macro-esthetics, as well as gingival and face esthetics

  1. Correction of teeth alignment: Though some amount of discrepancy in the alignment can be managed by a restorative procedure, the biologic and more holistic approach for managing malaligned tooth is through orthodontia (removable or fixed braces)

  2. Crown lengthening: Often, restoring the badly broken tooth requires exposure of crown margin, which can be accomplished via periodontal surgery or extrusion using orthodontic force. Orthodontic extrusion, though time-consuming, provides a more biological option by maintaining the biologic width

  3. Space closure[55]

• Prosthodontics: Prosthodontists primarily contribute by replacing the missing teeth. The different options include removable prosthesis, fixed prosthesis, and implants. Dental implants can be used to replace both face and oral components. They have the ability to keep prostheses in place and repair the abnormalities caused by clefts, facial deformities, tumors, and trauma[56]

• Oral and maxillofacial surgery: often, facial deformity, including musculoskeletal defects, affects the esthetic outcome of the treatment. Few cases cannot be masked or corrected by restorative or orthodontic treatments alone and require surgical management.[57]

What is the role of high-end technologies like cad-cam and magnification in esthetic dentistry clinical practice?

Over the past 30 years, the precision with which dentistry is performed has improved as a result of the advancements in technologies. The invention of the microscope and CAD-CAM has become one of the most significant revolutions in the dental field. Dentistry evolved from relying on what eyes see to visualizing the intricacies. However, the much-considered future since the early 1990s still seems to be in the future after 3 decades in India. The use of magnification is not only restricted to endodontics but also being widely used for flap surgery, tooth preparation and final restoration, oral surgical procedures, use of smaller bracket systems, and implant placement. The long-term advantages of magnification in dentistry far exceed the slight drawbacks, and its incorporation for routine cases will benefit not only the dentist but also the patient in terms of prognosis.[58]

The success of computer-aided design/computer-aided manufacture (CAD/CAM) technology has been fueled by recent advances in dental materials and computer technology during the last two decades. CAD/CAM makes the procedure more simplified, precise, fast and also helps in patient education. This technology allows dentists to use lasers and other optical scanning technologies to produce a virtual, computer-generated replica of the hard and soft tissues in the mouth. The impressions taken are non-invasive, more precise and the software shows a lack of adaptation.[59,60]

A study done by Yuzbasigolu et al. in 2014 suggested that patients prefer digital impressions over conventional techniques as they are more comfortable and time-effective.[61]

Once the scanning is completed, the restoration of the body is planned and calculated using a computer. Dental restorations are then created using a numerically controlled milling machine that forms the fundamental shape of the restoration.

Implementations of newer technology in esthetic dentistry clinical practice leads to:[62,63,64]

• Precision and perfection

• Fewer chances of complications and better outcome

• Preservation of more vital tissues

• Better field of view

• Accuracy

• Less time consuming

• Simplified and less wastage of material

• High patient acceptance.

CONCLUSION

For decades the smile design concept has been static and stenciled into specific mathematical proportions or formulae. However not all smile designs will look good on all the patients; that is “one size fits all” approach does not work in esthetic cases. If the final smile design of one patient is copied and pasted to another, it may not give as pleasing results as the first smile. The macro and micro esthetic design is not a finite point and the esthetic case planning should not only be fuelled for biological, functional, structural, and esthetic parameters but also the personality/psychology of the patient.

Each individual displays a different incisal silhouette, tooth shape, size, and color out of many possibilities. To build a precisely beautiful smile for the individual, the visual language of the patient's facial perception and personality must be carefully studied so that it is reflected in the smile; thereby, the patient should not be a passive recipient of the treatment but the co-creator of the smile.[41,42]

The formation of global esthetic guidelines and strategies based on the calculation of natural esthetic parameters; the progress of tooth whitening and innovative restorative as well as prosthetic materials and techniques; and, most recently, the implementation of digital technologies in the 3-dimensional planning and realization of truly natural, individualized prosthetics have been among the most notable advancements in dental esthetics over the last decade. However, in our country, a complete three-dimensional (3D) digital system is yet not extensively utilized, which may change in the future as more clinicians use digital scanners, 3D printers, and CAD/CAM.

However, taking all the available literature from the country till now, there is still a need for further studies from various aspects. These include future studies in the Indians, studies using videography as an evaluation method, designing studies with the adequacy of sample size, eliminating Gender Bias, Studies on Facial Form, Sexual Dimorphism, and Tooth Colour, and the Need for Geographically diversified sample size representative of ethnic groups in India.

Financial support and sponsorship

The colloquium was supported by Shofu, India.

Conflicts of interest

There are no conflicts of interest.