Using The RED Proportion Template To Create A Beautiful Smile

E s t h e t i c sUsing the RED Proportion Templateto Create a Beautiful SmileDaniel H. Ward, DDSIt has been said that people haveto see it to believe it. Cable television shows now feature youngcouples searching for run-downhomes they can purchase for abargain and then transform intothe house of their dreams. Theproperties may appear hopeless,but the realtors can often envisionthe potential in their own minds.They rely on cad-cam computerimage programs to demonstrateto the potential buyer, the final remodeled appearance of the home.The buyers are often surprisedand proceed with the project oncethey can visualize the potentialoutcome of their investments.This is true for aesthetic dentistry as well. The dentist can often see the potential for an attractive smile but must demonstrateto the patient the potential final results. Important treatmentplanning decisions can be bettermade when the consequences ofthese decisions can be viewed.Only after effective visual com102oralhealthApril 2014 munication with the patient, caninformed choices be made thatwill ultimately satisfy the patientonce the treatment is complete.Before the era of digital photography and image manipulation, dentists had to rely on photographs of other patients eitherthey or other dentists had treated.The patient was asked just toimagine what this smile wouldlook like in their mouths. We allhave had patients bring in smilesof models or stars they have seenin a magazine and been asked torecreate their look. Unfortunatelythe “look” they are seeking maybe much more than just the teethand they are frustrated whentheir overall appearance does notmimic the celebrity.In the early days of smile design the author used to take smilephotographs of patients and traceout the outlines of the lips and ofthe teeth (Fig. 1). The new smiledesign was traced on a piece ofclear plastic and the patient wasasked to imagine in their ownminds what the smile would looklike with the tracings (Fig. 2).Obviously, this is an ineffectiveway to adequately communicatethe final results to the patient.Figure 3 shows the completedcase.Following the advent of computer imaging programs, simulations of smiles could be created.There are several types of programs that are available. Dentalcompanies developed programsthat allowed the user to outlinethe silhouette of the lips and toinsert the teeth and gums of otherpatients from a smile library(Figs. 4 & 5). Though quick andeasy, this technique can result ininappropriate and unrealistic expectations of the final results anddissatisfied patients (Fig. 6). Abetter way to simulate the potential final appearance of a smilemakeover is to insert the teeththemselves under the lips andwww.oralhealthgroup.com

E s t h e t i c sFigure 1—Tracing of teeth on tissue Figure 2—Pre-op photo overlaid with Figure 3—Completed casepaperdesired tooth tracingFigure 4—Simle to be imagedFigure 7—RED ProportionFigure 5—Smile image with area within Figure 6—Smile image with area withinlips removedlips replaced with teeth & gums fromsmile libraryFigure 8—Different RED Proportions fordifferent tooth lengthsFigure 9—RED Template Overlayover the gingiva of the patient’sphotographed smile. Clinical experience and expertise shouldguide the dentist to determine thefinal potential tooth and gingivalappearance.It has been advocated that theproportions of the teeth are important to achieve smile unity.1-2Dentists should design smilesthat are consistent with the sizeof the face and the body. Tallpeople generally look better withwww.oralhealthgroup.com tall teeth and short people arebetter matched with shorterteeth.3 Given a fixed intercommisural width, there are an infinitenumber of ways that the spacecan be allocated.4 Research hasshown that dentists prefer smilesin which the width/length ratio ofthe maxillary central incisors are75 to 78 percent.5 A tall personwould be better suited with a correspondingly wide central incisor.Less space is left for the remaining anterior teeth and thereforethey will be narrower.The successive tooth appearance widths of the maxillaryteeth as you proceed distally havebeen studied. A lateral incisor,which is 66 to 70 percent of thecentral incisor, has been observedin nature or has been preferred bydentists when evaluating smileswith normal length teeth.6-7 Tallteeth with corresponding widercentral incisors result in less remaining space making a smallerApril 2014oralhealth103

E s t h e t i c sFigure 10—Smile image with RED Figure 11—Smile image complete using Figure 12—Pre-treatment photoProportion template inserted in area RED Proportion templatewithin lipsFigure 13—Pre-treatment photo with RED Figure 14—Imaged photo for eightTemplate overlayrecommended restorationstooth width proportion necessary for the lateral incisor. The“Golden Proportion” or 62 percent RED Proportion has beendemonstrated to be preferred bydentists surveyed for very tallteeth. 8 The RED Proportion104oralhealthApril 2014 stand for “Recurring EstheticDental” Proportion which evaluates the successive tooth widthsof the maxillary anterior teethas you move distally and suggests that this proportion remainconstant9 (Fig. 7). In other words,Figure 15—Re-imaged photo for sixrestorationsthe appearance width of eachtooth diminishes by the sameproportion as you progress distally. This concept may be usefulas a guide in designing smiles.Using this concept, short teethresult in maxillary anterior teethwww.oralhealthgroup.com

E s t h e t i c sFigure 16—Completed treatment with six Figure 17—Taller tooth gives widerteeth restoredCentral Incisor narrower othersmore similar in size and a largerRED Proportion (Fig. 8). TheRED Proportion seeks to designsmiles in harmony with the face.Alterations to the gingival levelsof the teeth will affect the recommended proportions of the teethand may allow tooth length tobetter coincide with body length.A template has been createdwith outlines of the teeth atthe preferred 78 percent width/length ratio and different REDProportions (Fig. 9). The dentistcan overlay the template on thesmile photo to evaluate the different proportions. Once the appropriate proportion has been determined, the teeth can be “rubberstamped” within the outlines ofthe template to create the desiredappearance or teeth from a proportioned smile library can beinserted (Figs. 10 & 11). This is amore realistic outcome than theearlier displayed simulation froma smile library.This technique can be very useful in showing patients the effectof how many teeth are treated.This patient presented with achief complaint that he did notlike the gray areas in the proximal areas of the maxillary leftlateral incisor (#22), which wasa pontic for a Maryland Bridge.Photographs were taken and thecanted incisal plane was revealedwww.oralhealthgroup.com (Fig. 12). It was recommended dueto decay that the Maryland Bridgebe replaced with an all-ceramicbridge (#21-23) and laminates beplaced on the remaining maxillary anterior eight teeth (#11, 12,13, 14, 24). The RED Proportiontemplate was placed over the photograph (Fig. 13) and an imagecreated showing 8 treated teeth(Fig. 14). For economic reasonsthe patients asked that we reimage the photo and show whatsix teeth would look like (Fig.15). Based on this informationthe patient decided to only havesix treated at this time. The finalresults are shown (Fig. 16).Patients can also see the effect of cosmetic gum surgeryon the final tooth proportions.According to the principles of theRED Proportion, when maxillaryanterior teeth are lengthened, thecentral incisor should be widenedto maintain the ideal 78 percentw/l ratio. The remaining anteriorteeth become narrower. Figure17 shows the effect of longer central incisors on the remaininganterior teeth width proportions.The patient presented unhappywith her smile. Photographs weretaken and analyzed (Fig. 18).The appropriate RED Proportionwas selected and the templateplaced over the photo (Fig. 19).The final recommended imagewas produced and approved byApril 2014oralhealth105

E s t h e t i c sFigure 18—Pre-op smileFigure 19—Pre-op smile with RED Smile Figure 20—Imaged smile using REDTemplateProportion TemplateFigure 21—Full smile post perio surgeryFigure 22—Completed treatmentthe patient (Fig. 20). The patientwas referred to the periodontistwith the preferred tooth dimensions and surgery performed. Thepatient returned and asked thattemporaries be placed over thetwo central incisors during healing due to the unaesthetic appear-ducible. The imaged photographsare useful in communicating withthe patient and specialists. Intoday’s world of “try in before youbuy it” and “show me first” a visual simulation of the final smileappearance can be a useful formaking “informed consent” deter-Calloutance (Fig. 21). The gingiva was allowed to heal, the teeth preparedand 10 crowns placed (Fig. 22).minations with patients prior tobeginning any active restorativetreatment. OHThe RED Proportion is a valuable tool in creating smiles proportioned to the face and smile.The use of the RED Proportiontemplate makes it easier to createimaged smiles that are re-pro-Dr. Ward is in private practice in Columbus, Ohio. He isa Diplomate of the AmericanBoard of Aesthetic Dentistry, aFellow of the American Society forDental Aesthetics, a Fellow in the106oralhealthApril 2014 International College of Dentistsand a Fellow in the Academy ofGeneral Dentistry. Dr. Ward lectures and writes Internationallyon Smile Design, Digital DentalPhotography and RestorativeDentistry. He can be contacted atdward@columbus.rr.com.REFERENCES1. Lombardi RE. The principles of visual perceptionand their clinical application to denture esthetics. JProsthet Dent 1973:29:358-382.2. Gillen RJ, Schwartz RS, Hilton TJ, Evans DB. Ananalysis of selected normative tooth proportions. IntJ Prosthodont 1994;7:410-417.3. Boucher CO. Swenson’s Complete Dentures 6th ed.St Louis. C.V. Mosby, 1970.4. Ward DH. Using the RED Proportion to Engineer thePerfect Smile. Dent Today 2008;27(5):112-117.5. Rosenstiel SF, Ward DH, Rashid RG. Dentists’Preferences of Anterior Tooth Proportion-A Webbased Study. J Prosthodont 2000;9:123-136.6. Preston JD. The golden proportion revisited. JEsthetic Dent 1993;5:247-251.7. Fayyad MA, Jamani KD, Aqrabawi. Geometric andMathematical Proportions and their Relations toMaxillary Anterior Teeth. J Contemp Dent Pract2006;7(5):62-70.8. Ward DH. A Study of Dentists’ Preferred MaxillaryAnterior Tooth Width Proportions: Comparing theRecurring Esthetic Dental Proportion to OtherMathematical and Naturally Occurring Proportions.J Esthet Restor Dent 2007;19:323-336.9. Ward DH. Proportional smile design using the REDproportion. Dent Clin North Am 2001;45:143-154.www.oralhealthgroup.com

proportion as you progress dis-tally. This concept may be useful as a guide in designing smiles. Using this concept, short teeth result in maxillary anterior teeth Figure 10—Smile image with RED Proportion template inserted in area within lips Figure 11—Smile image complete using Figure 12—Pre