Complete denture esthetics

COMPLETE DENTURE ESTHETICS

Introduction
Denture esthetics is defined as the cosmetic effect produced by a dental prosthesis
which affects the desirable beauty, attractiveness, character and dignity of the
individual.

The subject of esthetics is not a totally scientific and objective discipline

nor is it 100% an art form . Esthetics is a combination of the art and the science
of prosthodontics.

Hardy said it best when he wrote "make the teeth look like natural teeth.
If a dentist is to make a denture, where in the teeth look they grew there, teeth
must be set in an esthetic and convincing arrangement that also meets the patients
functional needs.

It appears that beauty really does lie in the eye of the beholder and more
often is a matter of genetic programming of course, there are individual as well
as cultural variation. A denture is usually perceived as esthetic when the teeth and
bases are in harmony with the facial musculature as well as size and shape of the
head. Pre extraction records, old casts, photographs or Immediate dentures can be
extremely helpful both for tooth selection and arrangement.

The subject of esthetics should be examined from 3 points of view -

biological - physiological, biomechanical and psychological.

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 Complete denture esthetics

Biological - physiological

It is necessary to have an understanding of facial musculature, normal

facial appearance, and the physiological limits within which esthetic
compromises are to be made. A proper impression procedure is necessary to
provide the dentist with a final maxillary cast that has an accurate representation
of the labial vestibule and all of the other remaining structures.

1) The dentist should also have a visual concept of the cause and effect
relationship. eg: - If an edentulous patient has a tight, drawn & thin lips,
proper support with a fully formed occlusion rim and lip support by the
labial 2/3 of the artificial maxillary anterior teeth, should evert the
vermillion border of the lip. This would -afford a much more natural
appearance.
2) As patients become older the natural lines of farce tend to deepen and to
appear accentuated and the elasticity of the facial musculature is lost.
There is a tendency to want to plump out the face with additional
thickness of the denture base material and the musculature tends to loosen
the denture or the facial appearance, becomes strained.
3) Another approach to removing facial wrinkles is to Increase the VD. This
approach is fraught with the greatest of dangers and must be used with
caution. The actual process of trial placement of the maxillary anterior
teeth and the function of the maxillary and mandibular anterior during the
production of speech give one of the best guidelines for creating and
maintaining an adequate inter occlusal distance. The following principles
should be followed in the placement of anterior teeth.

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1) The lower anteriors should be placed lower in order to maintain an

adequate interarch space. This will necessitate lowering of the occlusal
plane posteriorly. This will have the effect of placing the teeth closer to the
mandibular ridge giving stability to the lower denture.
2) The maxillary teeth should be moved slightly more anteriorly at the incisal
edges. Tilting the incisal edges of the mandibular incisors; lingually
should be avoided. According to Muysigmes for every lmm the incisal
edges of the mandibular anterior teeth are posterior to their normal
arrangement, the tongue is deprived of approximately 100cub mm of
space in which to function.
Biomechanical
There are certain mechanical limitations in the placement of anterior teeth
that must be taken into account. The anterior teeth should be placed closely in
relation to the residual ridge as were the original natural teeth. Fish says the
proper position for the teeth is not necessarily on the ridge, inside the ridge, or
outside the ridge, but at a point where the tongue and cheek pressures balance.

Psychological
Patient's self image is an important factor in esthetics. -:A patients
perception of his or her appearance may result in a broad simle (if it is a positive
self evaluation.) or a tight - lipped, small, controlled smile, A patient with a poor
self image may appear done, unsure, questioning and introverted,. A patient with
a more positive feeling tends to smile more broadly.

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Camper’s line may be thought of as a psychological plane of orientation.

In a person who appears happy this line tends to rise and in a person who to
depressed it may slant downward.
The occlusal plane established by the dentist has an effect in determining
the appearance of a patients psychological state. eg: - by effecting a downward
slant to the plane posteriorly an observer may gain a negative impression of the
patients emotional or phychological state.

ANTERIOR TOOTH SELECTION

There are many methods of choosing anterior teeth for the edentulous
patients. Anterior tooth selection is a tentative step, which can be verified only by
the dentist utilizing the trial base and confirmed by the patient and family or
friends.
The best time to gain insight into the esthetic problems of a patient is the
first time we meet the patient. The decision should be made at the first visit
about the shape, shade, position and mold of the teeth to be used. If the patient
had a previous set of dentures, changes to be made can be discussed with the
patient.
A smile is the most visible record of a dentists care of an edentulous
patient. interior tooth selection is the area of prosthodontic care in which the
patient should be given a primary responsibility to determine the esthetic
outcomes.
A.T.S. has been based on theories that, tooth shape relates to head shape
and tooth appearance, is influenced by patient aye, sex and personality. Our aims
is to achieve a harmonious blending of shade, shape, arrangement and position so
that the final result is a removable restoration that creates an illusion of being
what it is not shade Krajicek states, is not so important what shade is selected,
but a variety of shades of teeth be used in a single 6 tooth composition .

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A study by Hallarman showed that there is apparently little correlation

between either natural hair or eye colour and tooth colour. There is also little
correlation between skin colour of the forehead or cheek and patients own
anterior teeth. His study also confirmed that canines are darker than the central
incisors and colour darkens with aye. Females tends to have lighter natural teeth
than to males.

Colour has basically 3 qualities hue saturation and brilliance.

Hue is the dimension of colour by which the eye distinguishes different wave
length of the visible spectrum. It is specific colour produced by a specific wave
length of light acting on the retina of the visible spectrum. It is possible to
recognize 2 different hues in artificial teeth one yellow and one red. The
individual teeth of each set, although of the same hue, should vary in their purity
the central incisors being more pure than the lateral incisors and canines. If
artificial teeth are to resemble pleasing natural teeth they, too under all conditions
of lighting should appear to be warm and living.
Saturation (Chroma)
It is the amount of colour/unit area of an object eg: some teeth appear
more yellow than others.
When more of the hue or less of white is present, there is said to be greater
saturation. A tooth is said to be darker because of an increase in saturation or a
decrease in brilliance. Both brilliance and saturation must be held within limits
and must be related to each other in correct proportions for each hue natural tooth
colours are to be imitated.

Brilliance (Value)

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Refers to the lightness or darkness of an object. It is the quantity of light

reflected from the surface. The inclination of surfaces, position of surfaces,
character of surfaces and the intensity of the projected light all affect the
lightness of an object.
Curved surfaces appear more darker than the surfaces at right angles to
light. Surfaces closer to the observer will be lighter than similar surfaces further
away. Polished surface will reflect more of than light received and will be lighter
than roughened surfaces. Surface appear lighter when it is illuminated by Intense
light.
People with fair complexions generally have teeth with less colour and are
lighter. People with dark complexions usually have darker teeth. However a light
teeth in the mouth of a patient with very light complexion may appear dark.
Likewise dark teeth in dark complexion appear to be lighter than they are.
Translucency
It is the property of an object that permits passage of light through it.
Translucency of artificial teeth has the effect of mixing the various colours of
teeth. This results in teeth that look alive. A natural tooth is composed of a
slightly translucent ivory colored body covered with a jacket of almost colourless
material of greater translucency. Because the enamel jacket varies a great deal in
thickness in different parts of the mouth, many characteristic visual effects are
produced.

Shade Selection
Colour of the teeth should be in harmony with that of the face. Women
usually tend to have lighter teeth.
Other factors are
1) Hair colour 2) Colour of the eyes 3) Age Hair Colour according to Bcucher
is not a constant factor and can be unreliable & inaccurate Colour of the eyes;

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Ace to Heart well it is an excellent guide but is not quite so according to

Boucher as he says that
- The iris of the eyes is so small compared to the area of the total
face & the eyes are not close to the teeth.
Age & Tooth colour
Natural tooth colour changes with age. In youth the pulp chamber are
large and the red colour of the pulp affects the tooth colour. later the pulp
chamber becomes smaller due to deposition of secondary dentin. This makes the
tooth more opayue.

The general rule is that darker teeth are more appropriate in older patients
and lighter teeth in younger patients.
Shade guides are useful in the shade selection observation of the shade
guide should be made in 3 positions.
1.) Outside the mouth along the side of the nose
2.) Under the lips with only the incisal edge exposed.
3.) Under the lips with only the cervical end covered and mouth open.
The first step will establish the basic hue, brilliance & saturation. the 2nd
will reveal the effect of the colour of the teeth when the patients mouth is
relaxed. The third will stimulate exposure of the teeth as in a smile.

The colour selected should be so inconspicuous that it will not attract

attention to the teeth. The colour of the teeth should be observed on a bright day
when possible with the patient located close to natural light. The 'squint test' may
be helpful in evaluating colours of teeth with the complexion of the face with the
eyelids partially closed the dentist compares prospective colours of artificial teeth
held along the face of the patient. The colour that fades from view first is the one
that is least consipicious in comparison with the colour of the face.

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Size
The size of the teeth should be in proportion to the face and head .
Generally larger persons have larger teeth. Men usually have larger teeth than
women. This is especially true of the CI, which normally should be more
delicate in women.
Clinical judgement and experience are the criteria in selection of the proper
width and mold. The widely used methods for anterior tooth selection based on
facial and tooth size proportion are A. Pre extraction records.

1) Diagnostic casts prior to extraction

2) Most recent photographs of the patient before loss of his teeth.
3) Radiographs of the teeth.

B. Post extraction examination

If the patient is edentulous and wearing CD examine the patient with the
dentures and ask the patient what changes to be done in the new denture.

C. Anthropometric studies indicate

Measurement of the bizygomatic width and dividing it by 16 to arrive at
the approximate width of the maxillary central incisior. Dividing this
measurement by 3.3 will give the total width of the 6 anterior teeth.

D. Mark the corner of the mouth on the wax occlusion rim and this will
give the width of the maxillary anteriors.

E. Pound evaluates tooth width by measuring the distance from zygoma to

zygoma, 1 – 1.5 inches back of the lateral corner of the eyes. Length is , measure

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of the distance from the hairline to the lower edge of the bone of the chin with
the face a; rest. Dividing it by 16 will give the length of the central incisor.

frush considers mold, lip support, midline labial version, (speaking line),
smiling line, C position, LI position, cuspid position, spaces embrasures, buccal
corridor, long axis, gum line, and inter dental papillae.

(Among the more significant factors are the treatment of the incisal edge
and prominance an position of the teeth. Rounded corners & Curve contours give
feminine appearance. Prominent wide central with a great deal of incisal abrasion
an worn cuspid tips indicate the wear of aging combine with the projection of a
personality of strength an vigor)
Sharry, Boucher & found all agreed that size selection should be based on
facial measurements proportions. Two popular methods are there for
selecting the size of the tooth.

1. Based on the space available for placement of the teeth. The length of the-
maxillary central Incisor is measured from the Inclsal edge of the maxillary wax
rim upto the high lip line. Then vertical lines are scribed on the wax rim directly
down from the
right & left ala of the nose. The distance between these lines give a good
approximation of the width of the 6 max, anterior teeth and places the canine
near the commissures.
2) Based on the facial & tooth size proporation
Pound advocated the same 1:16 ratio described by House & Loop. Levin observed
that the width of the maxillary anterior teeth when viewed in the frontal plane lie within
the golden proportion of 1.681 ie, the CI is 1.681 times wider than the LI in a frontal
view.
Frush & fisher varied incisor length from the ideal according to the
dentogenic guidelines of age, sex & personality. The incisors tend to be longer in

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young individuals and is shorter in males than in females . Frush & fisher
emphasized the Importance of the incisal edges of the maxillary anteriors
following the contour of the smile line of the lower lip.

Tooth form (shape)

Berry in 1930's was probably the first to demonstrate correlation
between outline form of maxillary central incisor and inverted outline form of
face J. Leon Williams classified facial form as square, tapering, square tapering
and ovoid.
Follwing 18 years study on extracted teeth House. & Loop classified teeth
according to form. Their classification was based not only on the facial outline
form of tooth but also on mesio distal and gingivo incisal contours. They
proposed 3 pure typical forms - square, tapering and ovoid along with 6 other
combination forms ie, square - tapering, reverse tapering, ovoid - square, ovoid
tapering and square - tapering - ovoid. House hold that good esthetics could be
achieved only if the facial arches, and tooth shapes all were in harmony. In
addition he classified arch forms as square, tapering and ovoid.
Found also believed that harmony was the key to good esthetics. He not
only evaluated outline form of face in frontal plane but also in the sagittal plane.
Boucher also states that shape of tooth should be in harmony with facial
form . frush & fisher considered dentogenic factors when selecting tooth form, as
well as tooth size & shade. They advocated selective reshaping of artificial teeth
to account for the influence of age, sex and personality. eg: -to simulate the
attrition seen in old age,' soft delicate look of feminine dentition or the bold
vigorous look of a masculine dentition.
Each denture tooth was treated as an individual in terms of both form &
position. Over accentuate maxillary central incisors produce strength an boldness
in smile. This can be reinforced o softened by reshaping & positioning of

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maxlllary lateral Incisors. Position & shape of maxillary canine is of paramount

importance in achieving good esthetics.
Frush & Fisher recommend ovoid teeth for females and square teeth for
males. Frush also considers lip support, midline, labial version speaking line,
smiling line, spaces, embrasure, buccal corridor, aum line and interdental papilla
in esthetics.
Hallarman in the 1970's noted the attempts to correlate tooth form with
facial form, sex and personality do not stand up under scientific investigation.
But these give guidelines t translate esthetic concepts into technique.

Tooth Arrangement
Nelson, and later french wrote that the arrangement of the teeth is a far
more importer esthetic factor than mold selection. French illustrates how the
same dentures tooth mold c appear as either square, tapering or ovoid depending.
on how the individual teeth are arranged and how tt base is fabricated to frame
the teeth.

There are 4 steps in arranging denture teeth.

1) Proper Orientation of occlusal plane
The oclusal plane lies parallel -.to the campers line in the sagittal plane &parallel to
the inter pupillary line in the frontal plane, Occlusal plane plate designed by Dr. Frank.
Fox is a most useful tool for determining these relationships. The amount of incisal edge
visible below the related upper lip may range from 0 - several mm owing to variations
in lip length from very short to very long. The incisal length of the rim is adjusted (by
having the patient enuncial F & V sounds) to where the wet or dry line of the L/lip
makes light contact with the incisal edges of maxillary central incisor.

2) Careful development of wax rims in the space intended for artificial teeth.
Wax rims should be developed with great care to fill the space once occupied by
the patients natural teeth. The rims should offer adequate support for the soft
tissues. They should allow for esthetic buccal corridors. Orientation lines should
be scribed on the wax rim in the mldline, high lip line and 2 vertical lines in the

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canine area directly down from the ala of the nose. Arch form should be
harmonious with facial & tooth forms.
 Heart well & Rahn pointed out that mandibular teeth become more
visible with age. Vig & Brundo showed that the longer the upper lip, the
more visible the mandibular teeth become with age via & Brundo showed
that the upper lip, become of men displayed 1.23cm urban when the I/lip
was at repose, where as women, displayed 0.49mm Cade showed that
there is significant exposure of mandibular beyond age 40.

3. Placement of each tooth; in its correct anatomic position.

Should view the positon of each tooth in the frontal, sagittal & occlusal
planes. The incisal edges of the CI & canines rest on the occlusal plane. LI 1mm
short of the plane. In the frontal view the long axis of LI perpendicular to the
occlusal plane LI angle medially slightly, canines more medially than LI. The tips
of the canine should never be more labial than their necks. In occlusal view LI
face forward, where as the canines are rotated distally. In sagittal view LI flare
slightly in a labial direction. LI flare slightly more in the same direction. The
long axis of canines are nearly perpendicular to the occlusal plane.

Mandibular Teeth.
Frontal View - Long axis of CI perpendicular to the occlusal plane.
- LI tipped medially slightly
- Canines tipped more medially than LI
Sagittal view
LI are tipped in a labial direction slightly, long axis of LI nearly
perpendicular to the occlusal plane canines angle forward slightly.

4. Characterisation of the set up

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Lombard! felt that the LI make the best statement of the patients age, LI
cannot the patients sex. Canines reflects the patients vigor. Frush & Fisher
believed that dentogenics influence tooth arrangement as well as shade of tooth
selection. To highlight age they accentuated diastemata and rotations. Probably
the most popular characterisation technique is to crowed and tilt the mandibular
anterior teeth.

Denture Base
Sir Wilfred Fish in his extensive writing on the polished surface of
dentures elaborated on the direct influence of denture base contours on facial
esthetics. He says optimum esthetics depend on adequate soft tissue support
which in turn is directly related to proper base contours.
Frush & Fisher proposed convex, rounded and shortened papilla in older
patients. They also proposed the exposure of more of cervical root portions of
denture teeth in order to simulate ginglval recession in older individuals. They
recommended finer stippling for females and . heavy stippling for males. They
preferred to the tint the interdental pappila and muscle attachment areas with
deep shade of red. They used light shades to tint areas of hard tissue.

Characterization
A life like restoration can be obtained by simulating the anatomical
characteristics of oral mucosa with various stains.
It is of particular value in
1. Subjects with active upper lip
2. Persons with prominent pre maxllla
3. Persons like teachers & singers
4. Who expose more of denture base during talking < smiling.
5. Young edentulous patients

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Many others have advocated festooning o. stippling and staining of the

denture base. They also suggested use of preformed anatomic palatal and facial
gingival forms.
Rugae can be reproduced in denture for natural feel. A 0.003 guage tin foil
is adapted over the rugae area of the edentulous cast of trimmed. This is adapted
to the base plate after wax up so as t reproduced the rugae properly.

Colour Distribution in Gingiva

Basic pink used over hard tissue as attached gingiva.
Light red used for papilla & muscle attachments Medium red tones in
mucobuccal folds, rugae etc Purple blue in heavily plgmented gingiva mostly
attached gingiva papilla & marginal gingiva. Brown for heavily pigmented
gingiva.

CONCLUSION
Denture esthetics aim in creating artificial substitutes for lost natural teeth
to maintain harmpny, naturality and individuality. Every effort should be made by
the dentist to maintain true identity between artificial dentures and the sex,
personality and age of the patient.

REFERENCE
1. Bouchers prosthodontic treatment for edentulous patients - 9th edition
2. Essentials of complete denture prosthodontics Sheldon tinkler - 2nd edition.
3. Dental esthetics - John H. Lee
4. Complete denture esthetics - DCNA Jan. 1996 Vol. 40
5. Sheldon Winkler et al Characterization of denture bases for people of colour
JADA, Vol 81, 1970.
6. Characterization of denture bases DCNA April 1975 Vol 19.

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