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Case report central incisor is equal to its width plus 20%, the height of the lateral
A 32-year-old male patient, MPC, came to the clinic complaining incisor is equal to the width of the central incisor, and the width of
about severe bruxism and darkened dentition (Figure 1). During the lateral incisor is equal to its height minus 20% or the width of the
the initial examination, an anamnesis was performed as well as a central incisor.
clinical examination capturing all dental measurements. Extraoral The central incisors were 8mm wide and 7mm high. According
and intraoral photographs were taken, in addition to the request for a to the literature reviews, the width of this dental element was within
radiographic examination to perform the case planning. average. The Hufriedy Chu meter was used.
Under the 4D protocol, clinical evaluation follows the model below These measurements are based on averages found by Sterret (2003),
of dental and facial aesthetic analysis: Magne et al (2013), and Yamaguto and Vasconcelos (2005). It is
important to relate dental measurements and positions with the dental
1. Macro-aesthetics (Figure 2) – analysis of the relationship between arch and smile line height.
the teeth and the face by anterior view, 45° and lateral view. In this Once the measurements are defined, their application results in
case, we could see a reduction in the lower third of the face, reflecting proportional, harmonic and individualized smiles (Fradeani and
the loss of dental structure and disharmony in relation to the teeth and Corrado, 2006). Table 2 shows the application of the ‘rule of 20’ in the
bones of the jaw and mandible. planning of this case.

2. Micro-aesthetics (Figures 1 and 3) – analysis of each tooth and Wish smile
the lips and gums. Teeth were aligned, small and darkened with little In the same session, the ‘wish smile’ was performed (Figure 4) – a
gingival exposure, confirming the patient’s complaint. At this point, technique where the smile test is performed under the patient’s own
dental measurements were collected to be used for diagnosis and dental elements, without an adhesive system. The BLXL composite
planning. resin (Empress Direct, Ivoclar) was used, according to the measures
defined by the ‘rule of 20’.
3. Nano-aesthetics (Figure 1) – analysis of the tooth itself, considering A picture was taken and shown to the patient for analysis and
aspects related to optical properties, such as translucency and approval. Afterwards, a template can be made for filing approved
opalescence, which may be altered in patients with acid erosion. In this
patient, the teeth were darker due to the loss of enamel.
In the dental analysis, the ‘oral care always unique program’ was used
to diagnose and show the patient a clinical report of the teeth affected
by infectious diseases, caries, and gingivitis, as well as degenerative,
physical wear, chemical wear, and gingival retraction. Out of the 32
teeth shown, 14 were compromised with physical wear, representing a
total of 43%. The analysis of dental erosion was based on the adapted
BEWE Index (Table 1).
In this case, it was observed that of the 32 teeth present, 12 were
grade 1, eight were grade 2 and four were grade 3. A total of 24 teeth
were affected by dental erosion. Severe acid erosion was an important
factor in the loss of vertical occlusion dimension (Figure 8).
The dental measurements of the upper incisors were performed to Fig 1: First aspect of the patient’s smile – micro-aesthetics and nano-
start planning the ‘rule of 20’. According to the rule, the height of the aesthetics

Fig 2: Macro-aesthetics, 180° evaluation, with and without smile

Dental Practice i November-December 2023 i Vol 19 No 6 15