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Dentogenics in complete denture prosthodontics

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 INDEX


SL. PAGE
CONTENTS
NO. NO.

1. INTRODUCTION 2

2. TERMINOLOGY 3-6

3. HISTORY OF DENTOGENICS 7-9

4. DENTOGENIC INTERPRETATION 10-27

5. PRACTICE APPLICATION OF 28-32

DENOTGENICS

6. THE DYNASTHETIC INTERPRETATION 33-36

OF THE DENTOGENIC CONCEPT

7. CONSIDERATIONS IN DENTOGENICS 37-77

8. THE PRINCIPLES OF VISUAL 78-88

PERCEPTION AND THEIR CLINICAL

APPLICATION TO DENTURE ESTHETICS

9. CONCLUSION 89

10. BIBLIOGRAPHY 90-94

1
 INTRODUCTION

Dentogenics is the art, practice and technique of creating the illusion of natural
teeth in artificial dentures and is based on the elementary factor influenced by sex,
personality and age of the patient.1 Dentogenic concept is an adventure in the realm of
cosmetic art. It was once written that we greet the world with our faces.1
The face is the most visible part of the human anatomy, and it is the face, which
helps to determine our social acceptance, confidence and self respect. Facial
appearance is of great concern to everyone, for it is a significant part of self-image.
The loss of teeth, because of the effect on facial appearance, often creates tremendous
psychological trauma to the patient. The prosthesis can either enhance or distract
IURPWKHSDWLHQW¶VSHUVRQDOLPDJHGHSHQGLQJXSRQWKHQDWXUDOQHVVDQGDWWUDFWLYHQHVV
of its appearance.

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considerably easier when the prosthesis accomplishes two basic esthetic needs: the
portrayal of a physiologic norm and an actual improvement in the attractiveness of
VPLOH«´2 It should be the goal of dental profession to fulfill these two important
needs.

Beauty lies in the eyes of the beholder. The artistic abilities of dentists vary
IURPRQHWRDQRWKHU:KLOHDOPRVWHYHU\RQHDJUHHVWKDW/HRQDUGRGD9LQFL¶V0RQD
Lisa is a work of art, the artistic impact of the denture is much more subjective.
Mimicking the nature always works best. The dentist must consider both the anatomy
and the physiology of the face, as well as artistic principles, to achieve a natural
looking denture.

To achieve a more natural appearing denture, three ingredients are necessary; the
right teeth, placed in the proper position and held in place by a natural appearing
matrix (visible denture base).3

2
 TERMINOLOGIES

1. Esthetics

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sensibility or sensation.4
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VHQVDWLRQ(VWKHWLFVLVWKHDGMHFWLYHIRUPPHDQLQJ´UHVSRQVLYHWRWKHEHDXWLIXOLQDUW
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philosophy dealing with the nature of beautiful and with judgement concerning with
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SKLORVRSKLFDOWKHRU\FRQFHSWLRQRIDUWRUEHDXW\´

2. Dentogenic

Dentogenic is a coined word meant to convey, in reference to prosthetic

dentistry, exactly the same meaning as the suffix -genic imports to photograph in the
ZRUG SKRWRJHQLF $FFRUGLQJ WR :HEVWHUV 'LFWLRQDU\ ³HPLQHQWO\ VXLWDEOH IRU
SURGXFWLRQRUUHSURGXFWLRQ´

In our word dentogenic, we seek to describe only such a denture as is eminently

suitable, in that, for the wearer, the denture adds to person's charm, character, dignity
or beauty in a fully expressive smile. Dentogenics then, means the art, practice and
techniques used to achieve that esthetic goal in dentistry.

When dentogenics evolved, the full meaning of esthetics was carried into its
third dimension:

i. The wearer of dentogenic restoration must have an inner sensibility of well

being.

3
 ii. The viewer of a dentogenic restoration must perceive beauty or fulfilment of
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iii. The dentist who created the dentogenic restoration would feel deeply rewarded.

3. Composition

Composition means the act of combining elements or parts to form a whole.

There are various physical attributes of the elements of a composition that imparts the
aesthetic value. These attributes have to be studied to help identify the positive or
negative influence that they can have on the aesthetics of the composition. The
various physical attributes of the elements of a composition are contrast, unity,
cohesive and segregative force, symmetry, proportion, dominance and balance.

4. Contrast

It is that factor which makes the various elements of a composition visible. The
eyes can differentiate the parts of an object due to contrast of colour, lines, patterns,
textures etc. Without proper contrast it will be difficult to appreciate these objects
clearly. The relation between the different parts of the face (facial), the teeth and
gums (dental) made visible by the contrast constitutes the ³GHQWR-facial
FRPSRVLWLRQ´

5. Unity or oneness

³,WJLYHVGLIIHUHQWSDUWVRIWKHFRPSRVLWLRQWKHHIIHFWRIDZKROH´8QLW\FDQEH
either static, when repeated shapes or designs are seen as inanimate things, like the
composition of crystals, or dynamic and changing as in living beings. Unity between
different parts of the face, gums and teeth is essential to give the effect of oneness or
wholeness to the dento-facial composition.

4
6. Cohesive and segregative forces

Any element which tends to unify a composition is a cohesive force.

Segregative forces are those elements which break the monotony of the composition.
Naturalness has combination of cohesive and segregative forces. A proper mix of
segregative and cohesive forces adds variety to the composition making it more
dynamic and interesting.

7. Symmetry

It is the regularity of the arrangement of forms either from left to right as in

horizontal symmetry, or from a central point to the either side like a mirror image as
in radiating symmetry. The horizontal symmetry looks repetitive and uninteresting
while radiating symmetry looks dynamic and interesting. In a dento-facial
composition radiating symmetry of the teeth is more esthetically appealing and is
associated with youthfulness while horizontal symmetry is less appealing and is
associated with aging.

8. Proportion

To be able to give certain mathematical representation of beauty for

numerically expressing the relationship of the various units that combine to make a
composition, the term proportion is used.

The relationship of the various units which are different from each other in a
composition but are associated with each other through a certain repetitive
mathematical factor is the repeated ratio.

The proportion between the various elements of a harmonious composition, in

which the cohesive and segregative forces are equally balanced, which has its various
units in an aesthetically appealing repetitive proportion to each other is the golden
proportion.

9. Dominance

5
 It exists when a strong centralized structure is surrounded by well ±
demarcated, characterized structures. In a dento-facial composition it creates
immaculate unity leading to a harmonious composition. The absence of dominance
makes the composition weak. Colour, shape and size are the factors which can
control dominance.

10. Balance

It is achieved when there is an exact equilibrium between the forces present on

either side of the fulcrum in a composition. In dentistry it implies the balance of 20
elements in relation to the midline. If any elements are imbalanced on one side, then
to create a visual balance either these elements are moved towards the midline or are
counter-balanced with opposite elements to regain the balance. In balance the weight
of the elements far away from the fulcrum grows in importance.

Visual tension is the tension brought about by the presence of certain elements
that cause an imbalance in the given composition. If the presence of these factors is
closer to the fulcrum, the effect of the tension induced is more magnified as against
their presence farther from the fulcrum. A distally inclined lateral incisor on one side
is compensated by a more mesial inclination of the first premolar on the opposite side
to reduce the effective visual tension. These variations are naturally found in
dentitions explain the reason why sometimes irregularities in inclinations still
produce pleasant smiles.

Thus, an esthetic dento-facial composition has a centralized dominance and

among all its various elements there is unity, symmetry, harmonious proportions,
balance and a proper mix of cohesive and segregative factors leading variety to the
composition.

6
 HISTORY OF DENTOGENICS

In 1915 Leon Williams introduced the square, ovoid and tapering concept of
choosing the form of the teeth for dentures. A square face deserved square teeth; an
ovoid face deserved ovoid teeth and tapered face, the tapered teeth.

Origin of Dentogenics.
In 1936 Wilhem Zech, a master sculptor, had an idea that artificial dentures
were something more than porcelain blades adaptable to an edentulous residual ridge.
Zech's father was a dentist, and it was for his father that he first began to
produce teeth with something more than geometric design. Young Wilhelm Zech,
realized that every bone in the human face, as well as throughout the human body,
contributes to the total human personality.
In 1952, Zech realized that teeth are the instruments of personality and
projectors of vitality. Zech experimented with the molders, spacers and arrangement
of teeth in artificial dentures for his father, with an article concept of what belonged
in a twenty human's mouth. He ground and formed teeth, which by their
configuration would depict distinct styles and types of personalities. The soft rounded
feminine type; rugged, coarse masculine type. He changed the standard ovoid, square
and tapering concepts, and added artistic irregularity of surface along with proximal
formation, vigorous ridges and subtle body interpretations.

The Swiss Dent Foundation.

It was established in 1952, in Los Angels, California. Here, ideas were
exchanged, photographic results displayed and entire field of dental esthetics was
given full emphasis. The seminars conducted at the Swissdent foundation had
convened quietly and without fanfare.

7
 In a one-day seminar held at Swissdent foundation in 1955, a representative
group of about 25 practicing dentists, were handed two well made complete dentures.
Everyone was questioned to know whether they belong to man or woman and for
what age and personality of the patient do they belong to. Nobody could give specific
answers.
In contrast, two more dentures were also given to them, one upper denture
delicately treated with slight ascending curve to the incisor line and with soft
arrangement of teeth. The other was to look at it in the hand, a Grotesque
arrangement of craggy teeth, angular and rigidly placed. The first was immediately
identified as suitable for a young woman and the second meant for the old man.
When the photographs of hands of male and female were observed for a
moment, just by looking at we could guess that whether it belongs to woman or man.
So should there be an equally complementary appearance to the dentures either one
should wear.
Frush and Fisher advocated use of appropriate molds for males and females
rather than attempting to make a single mold work for both. A pictorial guide of these
three personality categories of men and women has been suggested. Frush and Fisher
also advocated rotational positional variance with individual anterior teeth to achieve
different light reflections, enhancing the appearance of vitality in non-vital
substances. This produced natural asymmetry.
Introduction of the influence of gender, personality and age on arranging
anterior denture teeth was revolutionary in light of what was being practiced by the
profession.

The SPA Factor.

Sears wrote that, when the laterals were nearly as broad as the other front teeth,
the denture is said to have a strong or masculine appearance. When laterals were
narrower than average, the denture is said to have feminine appearance. Reduced to

8
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³GHOLFDWH´PHDQW³URXQGHG´RU³VPDOOHU´

9
 DENTOGENIC INTERPRETATION

There are only two Sexes immediately identifiable upon sight, by their, hair
style, and all other visible features.
Age can be easily separated into young, middle or elderly and no patient in any
group deserves the tooth form or tooth color of either of the other classifications.
Personality is a bit more complex, but, again it can be of three types i.e.,
vigorous, medium and delicate.
In a study on dentogenic concept, author stated that the dentogenic concept is
an aesthetic philosophy. It considers gender, age and personality to restore the
SDWLHQW¶V GLJQLW\ DQG XQLTXH LQGLYLGXDOLW\ WKDW KDV EHHQ PLVVLQJ LQ IDU WRR PDQ\
prosthesis. The dynesthetic and dentogenic concept, when applied, provides a more
natural harmonious prosthesis, which not only is desired by patients, but also is a
quality of care they deserve. Outstanding aesthetics can be achieved by simple
guidelines using tooth moulds specifically sculpted for males and females, arranging
prosthetic teeth to correspond the sex, personality and age and sculpting the matrix
(visible denture base) with more natural contours. By employing dentogenic
principles and concepts, it is possible to restore their dignity and individuality.
Dentogenics is the guide and not a compulsion and thus our imaginative perception
eventually is given more freedom.5

DENTOGENIC INTERPRETATION OF THE SEX FACTOR.

A women is a woman from her finger tips to her smile and a man from his fists
to his smiles.2 Keeping a woman a woman and man a man, after each looses the
natural teeth has become so important a problem that modern day thinking
emphasizes that a dentist must be an artist and a sculptor with highly developed
perceptive qualities.
Just as the sculptor, with his hammer and chisel can create the beautiful
feminine image of a venus de milo or the musculine form of a Thinker thus can the

10
skilled dentist and technician together create the same flow of masculine or feminine
line in the denture.3
The goal of the study by Fernanda Ferreira Jasse in 2011 was to determine the
gender of patients based on the appearance of the anterior teeth in photographs.
Laymen and observers from different specialties were asked to determine the gender
of individuals based on the shape and arrangement of anterior teeth. There was no
statistical difference between observers and between each group of professionals and
the laymen group. An intra-observer agreement was not observed between the
evaluations. The results of this limited study indicated that it was not possible to
differentiate gender by viewing photographs of anterior teeth.7

The dentist as an artist.

It is fundamental in our thinking that the dentist can be both an artist and
sculptor. Each may be perfect in his own way, but just as artists renderings will vary,
so will the interpretations made by dentists vary. The goal is imaginative perception.
Imagine that you are walking along the street. A block away a woman walks
toward you. You perceive at that distance that she is a woman. As she walks
towards you, you gain an impression of her personality. As she passes you, you
immediately clarify her age, also whether she is extremely feminine or she is healthy
and athletic etc. These are the conclusions that a dentist must derive before he begins
the construction of denture.

The expression of feminine characteristics in the denture.

A glance at the schematic feminine form is sufficient to illustrate the
roundness, smoothness and softness that is typical of women. It is not only a part of
the body, but also of the spirit, typifying compassion and tenderness, sweetness and
mothers love.
The sculptor in his interpretation of feminity will keep to the spherical form. It
is called spherical instead of circular so as to identify the third dimension which is so
necessary for dentogenics and which has been minimized in customary esthetic
11
procedures. The sculptor by using the spherical form, imparts a sense of softness to
his subject which otherwise would be lacking. One can do the same by infusing that
feeling of soft feminity into the tooth and into the smile.
A study was conducted in 1980 to compare facial form as a guide for maxillary
central incisors. Two photographs of each student were made, one full face and the
other an intraoral view of the two maxillary central incisors. The outline forms of
ERWKPD[LOODU\FHQWUDOLQFLVRUWHHWKZHUHFRPSDUHGZLWKWKH³DFWXDO´DQG³DSSDUHQW´
face-forms in 70 subjects, to determine whether a close similarity of face-forms and
tooth foUPV H[LVWV ZKLFK ZRXOG VXSSRUW WKH ³ODZ RI KDUPRQ\´ PHWKRG IRU WKH
selection of replacement of teeth. The results of the investigation do not support the
contention of Williams but rather invalidate this method of teeth selection because
more than two thirds of the individuals showed no similarity between face-form and
incisor tooth form.8
In 1983 a study was put forth the purpose of which was to evaluate whether the
lay public perceives anterior teeth selected by Williams's typal matching method as
aesthetically pleasing. The theory was tested by laymen responding to questions
about photographs of three edentulous male and three edentulous female patients.
These patients were selected as representatives of square, tapering, and ovoid facial
forms. The photographs were portrait views of the patients wearing different dentures
displaying square, tapering, and ovoid teeth. Responses to the photographs
demonstrated a preference for square tooth forms over ovoid, and then tapering.
Overall, ovoid teeth were preferred for females and square teeth were preferred for
males.9

The expression of masculine characteristics.

A scheme of the masculine form illustrates the cuboidal, hard, muscular,
vigorous appearance, which is typical of men. However, masculinity goes beyond the
evaluation of physical appearance. Muscularity expresses aggressiveness, boldness,
hardness, strength, action and forcefulness. A basic tooth form, which expresses
masculine characteristics, shows vigor boldness and hardness.
12
 Just as a basic 'feminine' tooth form may be further individualized according to
the dentists own interpretation of the degree of feminity, so may the masculine tooth
form may be further treated.
By sufficient depth grinding and by further squaring the incisal edges of both
the central and the lateral incisors, the effective employment of the basic tooth form
can be seen in a man's smile. The grinding of the incisal edge should follow more of
straight line.
Typically, in a vigorous middle-aged man central incisors were placed in bold,
prominent positions and rotated with their long axis so as to bring the distal surfaces
slightly forward. The lateral incisors should be squared, positioned with their mesial
surface inward. The cuspid should be hardened by vertical position, rather by severe
abrasion grinding on the tip.

Sex interpretations by tooth positioning.

The positions of the incisal edges, the prominence of gingival portions of the
necks of the teeth, and the position of the body of the teeth reflect feminity and /or
masculinity.
Arch form. Round denotes feminity and squareness denotes masculinity.
Maxillary anterior teeth. In females, incisal edges follow the curve of the
lower lip. In males, central incisors are on a horizontal plane parallel with the lip,
the lateral incisors are above the plane, and the cuspids are on the plane.

Normally, for mature males, the incisal edge is seen with the lip at rest. A
middle-age man would have 1 mm of tooth visible below the lip at rest. For females
it should be 2-3 mm.
Central incisor. The two positions of the central incisor set in perfect
symmetry, are the starting positions for conventional tooth setups. First by bringing
the incisal edge of one central incisor anteriorly, one can create a position, which is
evident but harsh. However, if we move one of the central incisors from the staring
position out at the cervical end, leaving the incisal edges together, we have created a
harmonious lively position. This is the least noticeable of three positions.
13
 The second and most vigorous position is to move one central incisor bodily
anterior to the other.
The third position is a combined rotation of the two central incisors with the
distal surface, forward, with one incisor depressed at the cervical end and the other
depressed incisally.
All these 3 positions can be treated softly which is more favourable for women
or vigorously which is more favourable for men.
Maxillary central incisors are positioned approximately 7mm from the middle
of the incisive papilla for females. Males have thinner and more muscular upper lip.
Placement of their central incisors at a position 5 mm from the middle of the incisive
papilla is an excellent starting point in achieving decreased lip support.
Zakiah M. Isain in 2012 investigated the relationship of the maxillary central
incisors to the incisive papilla in wearers of complete dentures. The mean incisor
distance to the incisive papilla in dentate adults was 9.59 ± 1.00 mm, while the mean
incisor distance to the incisive papilla in complete dentures was 6.34 ± 1.87 mm.
Thus, in this sample of edentulous patients, the anterior teeth in complete dentures
were positioned approximately 3 mm closer to the incisive papilla, as compared with
the position of the central incisors in natural dentition, and did not duplicate the
position of the natural anterior teeth.10
Fabiana Mansur Varjao et. al., 2008 did a study to evaluate the use of the
center of the incisive papilla as a guide for the selection of the proper width of
maxillary dentures in 4 racial groups. One hundred sixty stone casts were obtained
from impressions of the maxillary arch of white, black, mixed, and Asian subjects.
The occlusal surfaces of the casts were photocopied and the images placed on a
digitizer. The most anterior and posterior points of the papilla and cusp tips of the
canines were digitized. Dentofacial Planner Plus software was used to calculate the
distance from a line passing through the cusp tips of the canines to the center of the
papilla, defined as the midpoint of the anterior and posterior points of the papilla.
Result showed that in all studied racial groups, there was no coincidence between the
center of the incisive papilla and the canine line. The utilization of the center of the
14
papilla would lead to the selection of wider artificial teeth. To conclude the method
of using the center of the incisive papilla is not accurate, but may aid in initial
artificial teeth selection for the racial groups studied.11
Lateral incisors. They can also impart a quality of softness or hardness to the
arrangement by their positions (Fig.1and Fig. 2).

Fig.1. This positioning of lateral incisors
imparts a quality of feminine
softness(Courtesy:Frush JP, Fisher RD. How
Dentogenic Restorations Interpret The Sex
Factor. J Prosthet. Dent. 1956;6:160-172.)
Fig. 2. A hardened smile for the vigorous male
can be achieved by rotating the lateral incisors
mesially(Courtesy:Frush JP, Fisher RD. How
Dentogenic Restorations Interpret The Sex
Factor. J Prosthet. Dent. 1956;6:160-172.)

The lateral incisor rotated to show its mesial surface, whether slightly
overlapping the central incisor or not, gives softness or youthful coquettishness to the
smile. By doing the reverse, that is, by rotating the lateral incisor mesially, the effect
of the smile is hardened.
We would select the soft position for the very feminine smile and hard
positions for vigorous male. Smaller lateral incisors with rounded incisal angles
appear more feminine than longer ones.
The cuspid teeth is set generally in the following three positions,
1) Out at cervical end, as seen from the front.
2) Rotated to show the mesial face.
15
 3) Almost vertical as seen from the side.
Prominent cuspid eminence gives to the cuspid greater importance and
therefore gives to the smile a vigorous appearance more suitable for masculine sex.
Cuspid in females, when viewed from the front distal surfaces rotated in
posterior direction therefore mesial surface is exposed. In males it is rotated less
resulting in exposure of mesial one third, when viewed from front. In lateral view the
cuspids for both sexes are vertical to the occlusal plane. When viewed from inferior
direction, the necks of the cuspids are in a slightly more labial position than the
incisal edges.
Frequently the main concern in arranging the first bicuspid in a maxillary
denture for a female patient is esthetics rather than function, because a woman
usually exposes more maxillary teeth than man when speaking, smiling or laughing.

The third dimension - depth grinding.

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denture.
We always need that feeling of depth, that third dimension, for realism. It is
used for women (spheroid shape) as well as for men (cuboid shape). The depth
grinding is done moderately for both men and women of average proportions. It
should be increased as an individual interpretation of the sex, personality and age of
the patient for e.g.; round-bodied woman and vigorous men and on to a point of
'bony' appearance exclusively for the most vigorous types of mascularity. Without
this factor of perspective or third dimension, the most perfect restoration will lack the
touch of authenticity of life. The depth grinding is done on the mesial surface of the
central incisor only.
We can use manufactured teeth with their technically imposed deficiencies to
fool the eye of the observer, by creating the third dimension by a depth-grinding
procedure as follows. With a soft stone, the mesial-labial line angle of the central
incisor is ground in a definite and flat cut, following the same curve as the mesial
16
contour of the tooth, in order to move the deepest visible point of tooth further
lingually. After this cut has been made, a careful rounding and smoothening of the
sharp angle made by the stone must be accomplished and a perfect polish must be
given to the ground surface so that it cannot be distinguished from a surface produced
by a glaze in a porcelain furnace.
It is necessary to develop the desired effect in depth grinding by a
consideration of 3 main factors: A flat, thin, narrow tooth is delicate looking and fits
delicate women (little depth grinding). A thick, bony, big sized tooth, heavily carved
on its labial face, is vigorous and to be used exclusively for men (severe depth
grinding).
For the average patient, a healthy woman or a less vigorous man, depth
grinding will be an average. The depth grinding reduces the width of the central
incisors, depends the severity of grinding to be accomplished. So a larger size central
incisor of the same mold should be selected.

DENTOGENICS INTERPRETATION OF THE PERSONALITY FACTOR.

In the case of normal social activity, the smile is the primary objective
personalities of a human being. Mere sex identity could not possibly complete our
requirements for a dentogenic restoration as we come to comprehend the reason for
the differences in feelings and appearances. We wonder, how popular television and
movies or even magazines would be if all people were reduced to one male and one
female type. Hence, regardless of whether this face and figure of ours are our fame
and fortune, nature has endowed us with something for more important, the dignity
and satisfaction of being an individual with a personality of our own.12
Interpretation of personality factor depends on our manipulation of tooth
shapes (molds) tooth colors, tooth position, and the matrix (visible denture base).

17
Personality and mold consideration.
Compared to age and sex, personality is most difficult to determine, and is the
best measure of each patients priceless individuality. The term mold selection is
dangerous in that it implies finality, which is impossible. Wilhelm Zech has given us
his concepts of the molds in the personality spectrum as in vigorous, medium and
delicate categories.
Naturally, the central incisors of any selected mold can be ground to shorten or
narrow the teeth to the required proportion to express the personality.

The use of personality factor.

Comprehensive use of patients personality becomes practical only if we limit
WKHH[WUHPHVRIYLJRURXVDQGGHOLFDWH6RPHWKLQJLQVWHDGRIµ7ULDODQG(UURU¶method
of repeated try-ins seems to be a very desirable goal.
The purpose of this study was to ascertain the influence of dental appearance
upon subjective ratings of personal characteristics, specifically social competence,
intellectual ability, and psychologic adjustment. Each participant was asked to make
judgments about the personal characteristics of the subject of a single color
photograph. Eight photographs of four different men were used, each with one of two
degrees of dental status (visible disease, no visible disease). Outcome measures were
SDUWLFLSDQWV¶MXGJPHQWVRIWKHVRFLDOFRPSHWHQFHLQWHOOHFWXDODELOLW\DQGSV\FKRORJLF
adjustment of the subjects of the photographs. Participants judged subjects with less
dental disease to be more socially competent, to show greater intellectual
achievement, and to have better psychologic adjustment. To conclude in the absence
of other information, the judgments an individual makes concerning the personal
characteristics of others are influenced by dental appearance.13

Personality spectrum.
To provide a working tool for dentists as regards the personality factor in
dentogenic restorations, they have conceived the personality spectrum, which has
color- band or vertical rainbow hues extending from red to violet (Fig. 3).
18
 Vigorous Medium Delicate

Fig. 3. Personality spectrum

The rugged, male extrovert could only fit into the bold, red end of the
spectrum. The shrinking violet type female could only belong at the right end of the
scale and the medium, normal type, male or female, would fit somewhere in between.
The three divisions of personality spectrum are,
1. Delicate type (green to violet band) - 5% Meaning fragile, fraile, the opposite
of robust.
2. Medium type (orange to yellow band) - 80% Meaning normal, moderately
robust, healthy and of intelligent appearance.
3. The vigorous type (red to purple) - 15% Meaning the opposite of delicate, hard
and aggressive in appearance, the extreme male animal.
Most vigorous patients are men and most delicate patients are women.

Artificial teeth and personality spectrum.



19
 Our illustrations of the analogy between sculptured artistry in animals and the
sculptured effect is possible in artificial teeth. (Fig. 4a,b,c)
a) Sculptured Giraffe delicate contours
b) Sculptured Llama represents Medium character or personality and
c) Sculptured Bull represents vigorous type

Fig.4a. Delicate Fig.4b. Medium

 Fig.4c. Vigorous

No one looks like a giraffe, a llama or a bull and the use of pictures of these
animals is only to demonstrate the artistic ability of sculptors in the interpretation of
varied character.
By selecting a mold of the delicate category, and using it in the mouth of a
frail, delicate person, we retain a harmony between the personality of the artificial
tooth and personality of the individual. A truly sculptured tooth of the medium-
pleasing category expresses a similar medium personality or character when viewed

20
in the mouth. Vigor, strength and aggressiveness, gives us harmony, when used in the
mouth of a very vigorous person.

Over characterization and personality.

Over-characterization means, over-accentuation of the form, color and
arrangement of artificial teeth as compared with average concept of an artificial tooth
and artificial tooth arrangement. Over-characterization is artistically necessary
because we are forced to use artificial media to create the illusion of reality. Since we
use artificial media to create our illusion of reality in the smile, we find good use also
for many of WKHDUWLVW¶VGHYLFHVDQGSDUWLFXODUO\WKHUXOHRIFRORULQWHQVLW\XVHGLQWKH
creation of perspective. For example, what we experience as an ugly over-
accentuation of colour texture in artificial teeth, when seen in hand, does not appear
as such in the mouth. The artistic license of over-accentuation in the tooth form,
color, and position is therefore, not a reproduction or copy of nature.

Performance of individual teeth in personality interpretation.

In dentogenics, the concept of the six anterior teeth as a group is not used.
Instead each tooth is treated as an individual in form and position to produce
independent personality effects in the patients mouth.
Central Incisors. Just as various actors on the stage have their parts to play,
being in the center and front of the stage, play the leading role. Thus the over-
accentuation of central incisors contributes the deserved strength and action of the
smile.
Lateral incisors. They are the supporting actors on the stage and convey the
hardness or softness, the aggressiveness or submissiveness, vigorous tendency or the
delicate tendency.
Cuspid. Must dominate the lateral incisors in color form and position, and
their treatment conveys either a strong, pleasant modern accent or an ugly primitive
accent to the smile.

21
 Bicuspid. Since dental arch is visible from molar to molar in an expressive
smile, the bicuspids are esthetically important. They must achieve individually
through variations of their long axis, and through variations of their color.
It is extremely effective to vary the shades of the bicuspid and molar teeth,
sometimes rather severely.

Importance of personality factor.

1) Personality is a practical and inspiring approach to primary mold selection. It
paves the path for further sex and age refinements, which are necessary to the
dentogenic restoration.
2) The consideration of the personality factor allows a realistic approach to the
problem posed by the necessity of using artificial substances to create an
illusion or reality in smile.
3) The personality factor has been shown to be one that can be employed
specifically for predetermination of esthetic results and can help to eliminate
WKH FRVWO\ DQG XQVDWLVIDFWRU\ ³WULDO DQG HUURU´ SURFHGXUH IRU REWDLQLQJ
acceptable esthetic results.
A study by Ali Kemal Ozdemir et. al., in 2006 was done to determine the
correlation between personality type and denture satisfaction of totally and partially
edentulous patients. Two hundred thirty-nine patients aged 31 to 78 years using
removable dentures were asked to fill out a questionnaire on their satisfaction with
their dentures with regard to esthetics, speaking ability, and masticatory function.
Personality types were evaluated using both the responses to this questionnaire.
Denture satisfaction of the patients with regard to esthetics, speaking ability, and
masticatory function was affected by personality type.13

THE AGE FACTOR IN DENTOGENICS.

George Payne James has written in his book Richelieu, "Age is the most
terrible misfortune that can happen to any man other evils will mend, this is everyday
getting worse".
22
 In each individual, age changes take place through the entire body, and the
teeth are no exception. To arrange teeth in disharmony with these changes is in a bad
taste, and final result will be unnatural.
There is beauty in advanced age as well as in youth. In the light of our esthetic
investigations, we feel this statement can be further elaborated to read, "Not only is
there beauty in advanced age as well as in youth, but also there is an additional
quality of dignity". Dignity can be attained only through the experiences supplied by
time itself. The maintenance of the illusive quality of dignity must be the
responsibility of the prosthodontist.
The aging process we see in the skin of mother is also apparent in the teeth. It
LV DSSDUHQW WKDW PRWKHUV DJHG WHHWK ZRXOG QRW EH DFFHSWDEOH LQ WKH \RXQJ JLUO¶V
mouth.

Management of the age factor.

Early youth shows mamelon formation on the incisal edges of the permanent
incisors14. As the fresh crisp bloom poetically expresses youth on the skin, so does
the young tooth convey the same brilliance of the recent birth, by the unbraided
bluish incisal edge and unworn depth of incisal enamel.
As life progresses the adolescent quality of the tissue disappears, and
simultaneously complete the coronal portion of the tooth comes into view, and the
teeth have arrived at their terminal eruption position.
With the advancing age one can see in the face, the grayness or whiteness
replacing the youthful hair color. Skin textures are not now as taut and smooth; time
and the vicissitude of life have affected their toll. Finally, the step becomes a little
faltering, the shoulders a bit stopped and chronological age line approaches the
terminal.
For simplification one can consider the age as two parallel lines (Fig. 5), first,
the chronologic or life line, beginning with birth and extending to one hundred years
and second, the mouth condition line of equal length upon each of which are points
23
designating ten-year periods. Then, if one considers how frequently we find
ourselves being called upon to construct complete dentures for individuals in their
thirties and some of younger age.

Fig. 5. Comparison of the chronological age and the physiologic age of a patient
(Courtesy:Frush JP, Fisher RD. The Age Factor in Dentogenics. J Prosthet Dent. 1957;7:5-13.)

Young says, "It is less easy for dentists to accept the fact that denture patients
desire a brand of denture esthetics closely paralleling the ideal esthetic values of the
third decade of life".

Age in the artificial tooth.

As the body of the female loses its curves, the teeth lose their curves. The
teeth of the male become squarer in form to complement added weight and
squareness of body.
The dignity of advancing age must be appropriately portrayed in the denture by
careful tooth color selection and by mold refinement, also by the intervention of such
characterization, as would be fitting for the personality and sex of the patient.
Color selection. Lighter shades for young people and darker shades for older
ones.

24
 Mold refinement. The mamelons are present at the incisal edge of the central
and lateral incisors. The cuspid presents a pointed tip, which is very sharp in
appearance. The mamelon is soon abraded away, and the

tooth assumes the youthful adult form evidenced by the enamel incisal edge of
visible depth and of bluish hue. Later the sharp tip of the cuspid wears down to a
more mature form. Teeth abrade with age. Central and lateral incisors abrade in
straight line and cuspids abrade in a curve. This results in flattening of the arch (Fig.
6 and Fig. 7).

Fig. 6. Dotted line shows the original Fig. 7. The changing cuspid with age
appearance of the incisal edges of artificial .Left youth center middle age right
teeth;solid line shows the incisor wear to be advanced age(Courtesy:Frush JP,
incorporated for a particular Fisher RD. The Age Factor in
patient(Courtesy:Frush JP, Fisher RD. The Age Dentogenics. J Prosthet Dent.
Factor in Dentogenics. J Prosthet Dent. 1957;7:5-13.)
1957;7:5-13.)

Erosion seen on the gingival third and the necks of teeth. This is imparted to
the artificial tooth, by careful grinding and polishing effectively, conveys the illusion
of vigor and advanced age. Grinding and the repolishing the ground surfaces can
accomplish this. Variable shading effects will be produced, as the ground surface
will reflect light at a different angle from the ungrounded portion of the tooth.
Diastema. It is seen very frequently in youth. It is present even more often in
the mouth of adult in advancing years, because of the drifting of teeth resulting from
premature loss of permanent teeth. In the past diastema was rarely used in the

25
dentures between maxillary centrals. Now the dentist is own artist, and with
thoughtful consideration of age factor. While arranging a dental composition the
diastema places in his hands a splendid opportunity to create successfully the illusion
of reality.
Other factors by which age interpretation may be further enhanced by a
consideration of the probable tooth loss and the consequent migration and drifting,
like as seen with the natural teeth in a person of the same age.
The maxillary anterior teeth can be arranged extruded by malocclusion cases
and the cuspids, with the tips extruding labially into the buccal corridor, creating
wide spaces or diastemas between the teeth, making tooth arrangement grotesque and
ugly. Wearing away of the natural teeth at the contact points creates spaces between
the teeth. Also migration of teeth creates spaces.
A close study of natural teeth in the mouth can avoid mechanical repetition of
the long axis of the teeth in nature. They do not appear to radiate from a common
center. It requires only the slightest rotation of a tooth to convey the something seen
in artificial teeth.
The natural teeth of older persons have areas that support restorations. These
restorations can be duplicated.
It is not the purpose of the dentogenic concept to reproduce the undesirable
results of age or to emphasize the mistake of nature, but it does seek to avoid
afflicting the individual with the even greater problem of appearing dentally out of
harmony with the physical personality.

Age in the matrix.

Periodontal changes that may occur with age are gingival inflammation, edema
with loss of stippling, recession due to loss of attachment. These changes can be
reproduced in complete dentures and will help to improve the esthetics, especially if
the gingival tissues and flanges are visible on speaking or smiling widely.
The matrix in the artificial tooth must be meaningful and not repetitive or
inartistic. Our attempt in dentogenic restorations is to achieve the appearance of
26
youth, middle age or old age, in the denture base, according to the age of the patient,
and according to the age of the other tissues of the body.
Particular attention should be paid not only to colour but also to the shape,
length and breadth of the interdental papilla in interpreting the age.
Today with very lifelike materials available, we can even feature the
interdental papillae, in such a realistic manner, as to greatly aid in the illusion of
reality.
In youth interdental papillae are freely stippled and pointed tight against the
tooth (Fig. 8.). As age increases, Massler says, "the attached gingiva lose their
stippled appearance and appear edematous and smooth, buccal mucosa is dry,
LQHODVWLF DQG RIWHQ ZULQNOHG´ $GYDQFLQJ DJH FDQ EH LQGLFDWHG DSSURSULDWHO\ E\
shortening the papillae and by raising gingival gum line, selecting long tooth,
contouring the wax and positioning the tooth properly to suggest recession.

Fig. 8. The interdental papillae above, of youth; Center, of middle age; below, of advanced age
(Courtesy:Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39(5):502-504.)

27
 PRACTICAL APPLICATION OF DENTOGENICS

It has three educational aspects2

i. Education of the dentist: The dentist cannot achieve an accomplishment if
he does not understand any more than the student. Artists can be expected
to produce a portrait comparable to that executed by a master pointer.
ii. Education of dental laboratory technician, they form the valuable assistant
to many dentist.
iii. Education of the patient: Without an understanding of the esthetic asset to
himself, the patient cannot be expected to desire or even to be willing to
submit to the innovations of dentogenics.

Education of the dentist.

Dentists who desire to excel in his work as a prosthodontist must strive to
become exceedingly familiar with the detail of natural dentition, particularly from the
esthetic point of view. He must become familiar with the dentogenic principles, that
he may be able to apply them for the benefit of the patient whenever possible.
There are number of cameras specially equipped for such work. If possible, the
pictures should be in natural color, they should include close-ups of the mouth with
the previous dentures in position or with whatever teeth may be present. They are
invaluable pre-extraction records. Making two pictures of the teeth at close range and
retaining one for the office records can build a most valuable reference library.
Dentist may study freehand drawing with a local artist.
P. N. Sellen et. al., in 2002 conducted a study the aim of which was to
investigate the variability in choice of dental staff to select teeth appropriate to the
age and sex of the individual with the aid of a series of three-dimensional guides.
Four three-dimensional guides were produced for use in the study. Fifty dentists were
asked to complete a questionnaire designed to assess the variability in selection of
anterior teeth appropriate for the age and sex of an individual. From this study it can
be concluded that there was little consistency in the selection of the shade, mould and

28
arrangement of anterior teeth appropriate for the age and sex of the individual by
qualified dental staff. The development and implementation of an aesthetic proforma
to guide dental staff, dental undergraduates and patients through the process of
choosing tooth mould, shade and arrangement based on age and sex may be helpful.17
The matrix or denture base is an exceedingly important feature of a denture. It
is expedient to refer again to the collection of magazine pictures of smiling people in
order to meet a possible objection by the patient to the shows of the interdental
papillae or gingival matrix.

Education of the laboratory technician.

Accurate communication between the dentist and the laboratory technician is
essential in complete denture prosthodontics. Unaided by the dentist, the laboratory
technician cannot produce a dentogenic restoration, because he does not come in
direct contact with the patient, nor is he professionally trained to meet the challenge
posed by the complexities of patient management.
$UPLQJ/DQGHFNDFRQWHPSRUDU\DUWLVWVD\V³,FDQSDLQWWKHDYHUDJHPRUHRU
less perfect egg from memory, and at times enjoy the illusion that I have invented,
but I would not care tR SDLQW D ZULQNOHG HJJ ZLWKRXW D PRGHO´ 6R WR SUHSDUH D
denture composition without seeing and studying the patient, could and frequently
result not only in incongruity but in distortion of the patients personality and
destruction of his morale.
When he is qualified, however, the dental laboratory technician by means of a
specific prescription form can apply the dynesthetic procedures, which are an
essential part of his techniques. Since the patient is known to the technician only
through the dentist, the ultimate success of the denture composition is in the dentists
hands. The wax occlusal rims forms the bridge between the laboratory technician and
the dentist. The Esthetic control base (ECB) with its two central incisors and the
relation record can be sent to the laboratory for the technician to establish the
horizontal plane of occlusion after maintaining the casts in an articulator
29
Education of the patient.
$OH[DQGHU 3RSH LQ KLV IDPRXV ERRN ³$Q (VVD\ RQ 0DQ´ gives us this
quotation "This education forms the common mind; just as the twig is bent, the tree is
LQFOLQHG´)LUVWZHPXVWDFTXDLQWRXUSDWLHQWVZLWKQDWXUH7KHGHQWLVWPD\HPSOR\
a loose-leaf notebook with plastic inserts under which may be placed pictures cut
from current magazines of the well known people who display excellent natural teeth.
The pictures should show natural teeth in the mouth in serious speech, and during
expressive smiling. Pictures should be selected to illustrate the dynesthetic phase of
the dentogenic concept, such as the variable long axis of the anterior teeth, active or
passive positions of central incisors, the soft and hard placement of the lateral
incisors, and the canines in the desirable and less pleasing inclinations, ultimately
patient education manual becomes an indispensable aid. This book will assist the re-
establishment of natures design in the mind of the patient and sharpen his recognition
of the artificial.
It has been said that people notice change before they notice any improvement.
The dentist must be thoroughly familiar with all the dentogenic and dynesthetic
factors in order make certain that the highest degree of beauty, charm, dignity and
character has been embodied in the composition, which he has created.
Once all the anteriors are arranged, check the trial denture in the patient mouth
it is not advisable to permit the patient from viewing at this stage. Lack of teeth in
WKHSRVWHULRUFKDQJHVWKHSDWLHQW¶VSHUFHSWLRQMXVWDVYLHZLQJWHHWKRQDWRRWKFDUGLV
difficult for a patient to appreciate.
The purpose of a study by Marinus et. al., was to investigate the relationship
between satisfaction with complete dentures and several causal factors. One hundred
thirty patients who received new dentures were investigated during their treatment.
The results showed that 33% of the variance in satisfaction with dentures could be
clarified by (1) the attitude toward dentures, (2) the quality of the dentures, (3) the
oral conditions (opposite of what was expected), and (4) the number of previous
dentures woUQ 7KXV WKH SDWLHQW¶V DWWLWXGH WRZDUG GHQWXUHV PHDVXUHG E\ D
questionnaire administered prior to his or her receiving new dentures, and the number
30
of previous dentures worn, are prospective indicators for satisfaction with new
dentures. The oral conditioQ DQG WKH SDWLHQW¶V SHUVRQDOLW\ VHHP WR EH XQLPSRUWDQW
IDFWRUV DV PHDVXUHG E\ D QHXURWLF ODELOLW\ VFDOH DQG E\ D ³KHDOWK ORFXV RI FRQWURO
VFDOH´ 2QO\ RI WKH YDULDQFH LQVDWLVIDFWLRQ FRXOGEH FODULILHGE\ PHDQV RI WKH
variables used in the study. Thus satisfaction with dentures for most patients is
individually determined and, for dentist and patient, is often unpredictable.18
A study was conducted by Jonathan et. al., to ascertain the influence of dental
appearance upon subjective ratings of personal characteristics, specifically social
competence, intellectual ability, and psychologic adjustment. A cross-sectional
analytic interview study was conducted with 201 undergraduates. Each participant
was asked to make judgments about the personal characteristics of the subject of a
single colour photograph. Participants judged subjects with less dental disease to be
more socially competent, to show greater intellectual achievement, and to have better
psychologic adjustment. To conclude in the absence of other information, the
judgments an individual makes concerning the personal characteristics of others are
influenced by dental appearance.19
The survey in 2006 by Michael Waliszewski, et. al., aimed to determine if
edentulous respondents could differentiate among three denture esthetic concepts and
if there was an overall preference among the three. Six edentulous test subjects were
selected based on age and smile criteria. One wax tooth arrangement was completed
according to each of the three esthetic concepts for a total of three wax tooth
arrangements per test subject. The three esthetic concepts followed were natural,
supernormal, and denture looks. Standardized full-face digital photographs were
made of each arrangement (three) during maximum smile for each subject (six).
These 18 photographs were included in a questionnaire. Respondents were asked
questions about their preference among the three randomly ordered concept
photographs for each of the six subjects. A total of 147 completed questionnaires
were analyzed. Results showed that natural tooth arrangements were preferred by
55% of the respondents, supernormal tooth arrangements were preferred by 19%, and
the denture look arrangements were preferred by 26%.To conclude within the
31
limitations of this survey, the questionnaire respondents differentiated between the
three aesthetic denture concepts. The tooth arrangement most closely resembling the
anatomical average was selected by 55% of the respondents. Demographic factors do
not significantly affect patient preference.20

32
THE DYNASTHETIC INTERPRETATION OF THE

DENTOGENIC CONCEPT

The dentogenic therapy of esthetics is a basic esthetic concept for all phases of
dentistry where appearance is a factor. It is with a conscious consideration of these
patients 'constants' (SPA), that the dentist has learned to apply his knowledge with the
most effectiveness.2
To construct a dentogenic restoration effectively is a matter of learning and of
interpreting the sex, personality and age of the patient properly in the denture. This is
done through detailed consideration of the three equally important parts of the
denture, the tooth, the position and the matrix.
The qualities of feminitis, masculinities, personality and the various
physicologic ages will be revealed in the smile as a result of the way we do act
interpretation. If the dentist and the technician properly treat the tooth, its position
and its matrix correctly, then the age of the patient is dignified in the smile.

Clinical development.
It is impossible to anticipate the maximum success in denture construction for
all patients esthetically, but we have narrowed the gap between "trial and error"
methods and have predetermined success, by interpretation of sex, personality and
age of the patient in the denture with the development of dynesthetic techniques.

Dynasthetic theory.
It is the secondary factor of a dentogenic restoration. Dynesthetics is a
FRPSRXQG ZRUG  7KH SUHIL[ ³G\Q´ LV WKH FRPELQLQJ IRUP IURP WKH *UHHN ZRUG
³G\QDPLFV´ PHDQLQJ SRZHU  %\ WKH LQFOXVLRQ RI WKH G\QHVWKHWLF SKLORVRSK\ ZH
experience an orientation in appearance identification.
The word dynesthetic is used with the meaning of dynamics applied to the fine
arts. In this application, it means producing the effect of movement or progression.
33
This dynamic value has been described as marking the difference between an artifact
(any object without life effect made by man, such as a spoon) and a work of art
(visual objects that are alive meaning, such as statue). In dynamic beauty, the beauty
is present and recognized in movement i.e., the operation of an intricate machine, the
flight of airplanes or birds, the running horses, the gyrations of aerialists, and the
tempo of music.
Dentogenic procedure is the application by the dentists of their rules in the
sequence of esthetic planning and is applied according to the sex, personality and age
considerations.
Dynesthetic techniques are not to be confused with dentogenic procedure. The
dynesthetic techniques are rules which concern, the three important divisions of
denture fabrication; 1) the tooth, 2) the position, and 3) its matrix (visible denture
base).

Physiologic shade selection.

Artificial tooth shades should be classified according to the physiologic color
changes seen in progressively aging, undiseased natural teeth. For instance, when a
permanent central incisor erupts, the mamelon is intact on the incisal edge and the
fresh, unmarred qualities of the teeth are essentially sealed in by an unbroken enamel
cap. Young teeth, therefore have a blue incisal edge due to the tight refraction
through the two layers of enamel. The body of a young tooth is usually a solid and
opaque color with very little or no color texture.
If one has to create illusion of natural dentition, e.g., for a young person, we
would select artificial teeth with a blue incisal edge and yellowish body.
About 30 yrs of age, the incisal mamelon is worn through, and the dentino-
enamel junction is exposed to the fluids of the mouth. Tobacco tar, food pigments
and bacterial discoloration change the unmarred qualities of natural teeth.
Older person, one should select a shade of artificial tooth which represents the
aging process, but this does not necessarily mean darker teeth for older people.

34
 A person who does not smoke and who takes foods with slight pigmentation
may continue to have a relatively light tooth body, together with normal color texture.
We must have shades available for older people, which are lighter than some of those
for younger people. This is physiologic shade selection.
Unsual or special shades are also seen in natural teeth. These occur naturally as
VPRNHU¶VVKDGHVFDQDU\\HOORZVKDGHVpink gray, gray, and gray-brown.
Special shades are needed mostly in fixed and removable partial dentures and
porcelain jacket crowns to match natural tooth colors (Fig. 9.).

Fig. 9. Physiologic shade selection (Courtesy: Frush JP, Fisher RD. The Dynesthetic Interpretation of the
Dentogenic Concept. J Prosthet Dent 1958;8:558-581.)

&RORUFKDUWIURP:HEVWHU¶V'LFWLRQDU\LVHDVLO\DQDO\]HGDQGXQGHUVWRRG7KH
axis of the double cone is called brilliance and brilliance is a measure of gray from
white to black (Fig.10.).

35
Fig. 10. A chart of color solid (Courtesy:Frush JP, Fisher RD. Dentogenics : Its practical application. J
Prosthet Dent 1959;9:914-921.)

36
 CONSIDERATIONS IN DYNESTHETICS.
Mold.
The personality spectrum as a measure of physical (objective) personality
remains as the best guide to mold selection (Fig. 11.).

Fig. 11. Personality spectrum.(Courtesy:Frush JP, Fisher RD. How Dentogenic Interprets
the Personality Factor. J Prosthet Dent.1956;6:441-449.)

This chart shows an effective adaptation of selected molds to the personality

spectrum for excellent results in our experience.
Personality mold selection A medium pleasing personality mold is made more
masculine by squaring the incisal edges, A medium personality mold is modified to
appear more feminine.(Fig. 12 and Fig. 13).

37
Fig .12. A medium pleasing personality mold Fig. 13. A medium personality mold is
is made more masculine by squaring the incisal modified to appear more feminine
edges

Refinement of mold selected is controlled by the manipulation of interdental

papillae, both in wax and finished plastic denture base. Further refinement is
accomplished by incorporation of sex factor, by curving the incisal edges of the
central and lateral incisors for women, and squaring the incisal edges for men. The
last refinement of selected mold is incorporation of the age factor by simultaneous,
abrasion (Fig. 14.), erosion (Fig. 15.), depth grinding (Fig. 16.) and diastema in the
central and lateral incisors cuspid and bicuspid teeth.

Fig. 14. (Left)The progressive abrasion of artificial tooth as the age of the patient progresses (Middle) the
cut made for normal abrasion to remove the artificial appearance of the incisal edge

38
Fig. 15. (Left) A posterior diatoric tooth to be modified to stimulate erosion. (Right) the subsequent grinding
and polishing presents an illusion of natural erosion which can be achieved similarly with anterior teeth in
lesser degrees

Fig.16. (Left) Depth perception is limited in the artificial tooth because that contact point is too near the
labial surface. (Right) The depth perception has been increased b depth grinding (Courtesy:Frush JP, Fisher
RD. The Dynesthetic Interpretation of the Dentogenic Concept. J Prosthet Dent 1958;8:558-581.)

Depth perception is limited in artificial tooth. Therefore the contact point is too
near the labial surface. It has been increased by depth grinding. (Fig.16.)

Lip support.

It is the bodily antero-posterior position of the teeth, which adequately supports

the upper lip in a natural and pleasing manner.3
The placement of upper anterior teeth for proper lip support is an independent
procedure. It may be modified to accommodate, but it is not controlled (Fig. 17).
39
Pleasing lip support is achieved by the anterior teeth and their matrix. The burden of
lip support is carried chiefly by the central incisors.

Fig 17. Pleasing lip support. Position A is for maximum mechanical stability; Position B, C and D represent
the progressive dynesthetic positioning of the central incisors for pleasing lip support (Courtesy:Esposito SJ.
Esthetics for denture patients. J Prosthet Dent 1980;l(44):608-615.)

Midline.

Anatomic landmarks used when determine the midline for maxillary dentures
are; nasopalatine papilla, midpalatal suture, and the labial frenum, for the facial
midline are Nasion and base of the philtrum.
In 1988 George H. Latta, conducted study with a total of 100 patients receiving
treatment for maxillary complete dentures was studied. The patients were 32 to 87
years of age; there were 33 men and 67 women; 50 were white and 50 black.
Findings included,
1. The average width of the mouth for the patients studied was 52.22 mm and the
width of the philtrum was 10.97 mm.
2. The width of the mouth and the width of the philtrum were determined to be
correlated, irrespective of age, sex, or race.
3. The overall means of distances from the facial midline to the nasopalatine
papilla, to the midpalatal suture, and to the frenum were less than 1 mm.

40
4. Approximately 70% of the distances were 1 mm or less, and the range varied
from 0 to 5.5 mm.
5. Neither these measurements of distances, nor the size of the mouth and
philtrum were affected by age.
3
6. The size of the mouth and philtrum were larger for men and black patients.
It is difficult to see a true midline in a dentition. It is usually more eccentric than
is noticed (Fig. 18). Therefore eccentric midline in a denture, if not too exaggerated,
is acceptable and may lend to the illusion of the natural dentition. The acceptable
midline always is straight line (vertical). An error in composition (slant) results when
the mid-axis of the central incisors is not vertical. Whenever possible, the midline
between the maxillary central incisor should be coincidental with the facial midline.4

Fig. 18. A, An acceptable midline (solid line).B, An error in composition which results when the mid
axis of the central incisors (solid line) is not vertical (Courtesy: Latta GH. The midline and the
relation to anatomic landmark in the edentulous patient. J Prosthet Dent 1988;59:681-683.)

Labioversion.
It is necessary because the most pleasing effect is obtained when the long axis
of the central incisors are either vertical or with a slight labial indentation.

Speaking line.

Is the incisal length or the vertical composition of the anterior teeth. When
patient is speaking seriously, one should see the tip of the lateral incisor (Fig. 19). A
guide to vertical composition using incisal edges of central incisors in their
relationship to the lip line, as a measure is as follows.
a) Young woman - 3mm below lip line at rest
b) Young man - 2 mm below lip line at rest
41
 c) Middle age - 1 ½ mm, below lip line at rest
d) Old age, senility - 0 mm below lip line at rest to 2 mm above the lip line at rest.

Fig.19. The speaking line (Courtesy:Esposito SJ. Esthetics for denture patients.
J Prosthet Dent 1980;l(44):608-615.)

Smiling line.
A pleasant smile may produce an aura that enhances beauty of the face, as it
pertains to the qualities and virtues of human personality. The smiling line is a curve
whose path follows the incisal edges of the central incisors up and back to the incisal
edges of the laterial incisors and hence, to the tips of the cuspids.3
This multicentre study by Marie Francoise Liebert et. al., in 2004 evaluated
peridontium visibility during natural and forced smile based on a new classification.
The study consisted of 576 patients aged from 21 to 78 years. All participants teeth
from first right premolar to first left premolar were present and the periodontium was
healthy. Clinical photographs of the participants were taken and smile line analyzed
according to the following 4 classification 1) more than 2mm of marginal gingival
visible or more than 2mm apical to the cement-enamel junction visible for the
reduced but healthy periodontium. 2) between 0 and 2mm of marginal gingival
visible or between 0 and 2mm apical to the cemento enamel junction visible for the
reduced but healthy periodontium 3)only gingival embrasures visible 4)gingival
embrasures and cemento enamel junction not visible .With natural smile analysis
revealed the following :class 1, 4.69% ;class2, 8.16%; class 3, 44.79% and class 4,
42.36%.With forced smile analysis revealed the following :class 1, 22.22%; class 2,
21.35%; class 3, 45.49% and class 4, 10.94%.The periodontium was more visible in

42
the forced smile than in the natural smile .Age and gender influence the position of
the smile line for only the natural smile.21
This study Anthony H. L. Tjan in 1984 formulates a standard of normalcy in an
esthetic smile relative to (1) smile type (high, average, low); (2) parallelism of the
maxillary incisal curve with the lower lip; (3) position of the incisal curve relative to
touching the lower lip; and (4) the number of teeth displayed in a smile. The standard
may serve as a guideline for restoration or enhancement of esthetics for the anterior
component of the dentition. High smile (S1. Reveals the total cervicoincisal length of
the maxillary anterior teeth and a contiguous band of gingiva. Average smile (S2.
Reveals 75% to 100% of the maxillary anterior teeth and the interproximal gingiva
only. Low smile (S3. Displays less than 75% of the anterior teeth.
Parallelism of the maxillary incisal curve with the lower lip. Three hundred
eighty-five (84.8%) subjects showed parallelism of the upper incisal curve with the
inner curvature of the lower lip, 63 (13.88%) showed a straight rather than a curved
line, and six (1.32%) showed a reverse smile line.
Position of the incisal curve relative to touching the lower lip. Three groups
were identified (1) the incisal curve of the maxillary anterior teeth touched the lower
lip (c1). (2) the incisal curve of the maxillary anterior teeth did not touch the lower lip
(c2). (3) the incisal portion of the maxillary anterior teeth were slightly covered by
the lower lip were not significant statistically.
The number of teeth displayed in a smile. The number of teeth displayed in a
smile was as follows: six anteriors only, 7.01%; six anteriors and first premolars,
48.6%; six anteriors and first and second premolars, 40.65%; six anteriors, first and
second premolars, and first molars, 3.74%.
The results of this experiment show that a typical or average smile has the
following characteristics.
1. The overall cervicoincisal length of the maxillary anterior teeth are displayed.
2. Gingiva does not show (except the interproximal gingiva).
3. The incisal curvature of the maxillary anterior teeth parallels the inner
curvature of the lower lip.
43
4. The incisal curvature may be either totally touching or slightly touching the
lower lip.
5. The six maxillary anterior teeth and the first or second premolars are displayed.
6. The midline coincides with a harmonious balance of the smile
7. Stereotyped feminine and masculine tooth anatomy characteristics could not be
related to the sample.22
Smile line is determined by the age of the patient and it decreases, as the
patient gets older. Curvature of the incisal line is more pronounced for women than
for men (Fig. 20). A reverse incisal line or an abnormal lower lip posture deeply
affects the degree of attractiveness of the smile.

Fig 20. A curve suggest softness. Grinding of the incisal line to create this curve express
feminity (Courtesy: Frush JP, Fisher RD. How Dentogenic Restorations Interpret The Sex
Factor. J Prosthet. Dent. 1956;6:160-172.)

Sharp curve of this smiling line is youthful. Broad curve of the smiling line
indicates an older dental composition. (Fig. 21 a & b).

Fig 21a. A Smile line ±A sharp curve is
youthful(Courtesy: Frush JP, Fisher RD.
How Dentogenic Restorations Interpret The
Sex Factor. J Prosthet. Dent. 1956;6:160-
172.)
Fig 21 b. Broader curve indicates older dental
composition (Courtesy: Frush JP, Fisher RD.
How Dentogenic Restorations Interpret The Sex
Factor. J Prosthet. Dent. 1956;6:160-172.)

44
Classification of smile.

Fig. 22a. Normal Fig. 22b. Gummy Fig. 22c. Toothy

Average smile (Papilla smile/gingiva smile)- About 75% to 100% exposure of

maxillary anterior teeth and the interproximal gingiva only.(Fig. 22a.) High smile
(Mucosa smile) ±full exposure of labial surface of teeth, interdental papilla, free
marginal gingival and labial mucosa. (Fig. 22b.) Low smile (Tooth Smile) -Exposure
of less than 75% of maxillary anterior teeth.(Fig.22c.)

Interincisal distance.
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ROGHU GHQWDO FRPSRVLWLRQ  ,QFLVDO HGJH DW µP¶ LQGLFDWHV D PLGGOH DJH LQWHULQFLVDO
GLVWDQFH7KHLQFLVDOHGJHµ\¶LQGLFDWHVD\RXWKIXOLQWHULQFLVDOGLVWDQFH

Smile Symmetry.
It refers to the identical placement of the corners of the mouth in the vertical
plane of the face which is more pleasing in appearance. Smile asymmetry implies to
the difference in the placement of the corners of the mouth in the vertical plane of the
face.
Gagandeep Kaur et. al., in 2011 in his article anatomy of smile described good
appearance is not considered a vanity sign, but literally a need, and the dentistry has a
fundamental role in obtaining it, since the face is the exposed area of the body and
mouth a prominent line. The smile constitutes an important component in the
presentation of a human being favouring his or her social acceptance. A non
harmonic smile decrease the beauty of the face and it can cause discomfort in the
social conviviality, as it is one of the important facial expression that demonstrates
45
friendship, sensation and appreciation. This study analyzed, the aesthetic components
of the smile, evaluating the relationship between the curve formed by the incisal line
of the anterior superior teeth and the curve of the lower lip, the touch of this incisal
line on the inferior lip and the number teeth displayed during smile. Three hundred
fifty Punjabi females above 19 years of age and having full dentition were selected.
Photographs were taken (Smile) using digital camera. Results show that a typical or
average smile has the following characteristics: 1) The overall cervicoincisal length
of the maxillary anterior teeth is displayed. 2) Gingiva does not show (except
interproximal gingiva) 3) The incisal curvature of the maxillary anterior teeth
parallels the inner curvature of the lower lip A) The incisal curvature may be either
totally touching or slightly touching the lower lip.23

Refinements of Maxillary teeth.

Stein in his treasure on this subject says "upper anterior teeth are like
fingerprints; there are no two alike. They vary from one individual to another. This
variability manifests itself in size, color, form, contour, and surface markings.
Selection and placing of artificial teeth will not appear natural unless they are
set with typical inclinations and rotation that the eye has been accustomed to seeing.
Some of the slight irregularities of maxillary anterior teeth that may appear
natural when reproduced are as follows: -
1) Overlapping the mesial surfaces of the maxillary lateral incisors slightly over
central incisors.
2) Maxillary lateral incisors depressed lingually so that the distal surface of
central incisor and the mesial surface of the canine are labial to the mesial and
distal surfaces of the maxillary lateral incisor.
3) Rotating the mesial incisal corner of the maxillary lateral incisor palatal to the
distal surface of the central incisor, with the distal surface of the lateral incisor
flush with the mesial surface of the canine.
4) Placing the incisal edge of the lateral incisor much higher than the incisal edge
of the central incisor and canine.
46
 Central incisor expresses age characteristics (Fig. 23.)
Lateral incisor expresses sex characteristics
Canine expresses personality
Bicuspid ± esthetics
First molar ± function is mastication
Second molar ± function is occlusal balance

Fig. 23. SAP Concepts: Sex, Age, and Personality (Courtesy:Morley J, Eubank
J. Macroesthetic elements of smile design. JADA 2001;132:39-45.)

Central Incisor Position.

When arranging maxillary anterior teeth positioning of central incisor is
paramount. They are not only the dominant actors on the stage of expression, but also
crucial in determining
a) The midline
b) The speaking line
c) The lip support
d) Labioversion
e) Smile line composition
They are the basis of personality mold selection. They are the first teeth to be
seen in the smile. Their shape is controlled by physical personality of the patient and,
their position determines the strength and action of the dentogenic composition.24

47
patients after dental rehabilitation with complete dentures. To examine the impact of
dentures on speech production, the speech outcome of edentulous patients with and
without complete dentures was compared. Twenty-eight patients reading a
standardized text were recorded twice ± with and without their complete dentures in
situ. A control group of 40 healthy subjects with natural dentition was recorded under
the same conditions. Speech quality was evaluated by means of a polyphone- based
ASR according to the percentage of the word accuracy (WA). Speech acceptability
assessment by expert listeners and the automatic rating of the WA by the ASR
showed a high correlation. Word accuracy was significantly reduced in edentulous
speakers FRPSDUHGWRWKHFRQWUROJURXS¶V:$2QWKHRWKHUKDQGZHDULQJFRPSOHWH
dentures significantly increased the WA of the edentulous patients .Speech
production quality is significantly reduced after complete loss of teeth. Reconstitution
of speech production quality is an important part of dental rehabilitation and can be
improved for edentulous patients by means of complete dentures.26
The relationship of the central incisor to each other is important. One central
incisor is always placed bodily ahead or behind the other (Fig. 25.). From this point
on, various degrees of rotation, labial inclination and axial divergence will produce
effects of additional strength, activity and vigor to the entire dental composition.

Fig 25. One central incisor is nearly always placed bodily ahead or behind the other central incisor
(Courtesy:Jameson WS. Dynesthetic and Dentogenic Concept Revisited. J Esthet. Restor. Dent
2002;14:139-149.)

49
 The irregularities of the central incisors may be developed by,
i. Overlapping of the labial incisal angle of one central incisor over the adjacent
central incisor;
ii. Placement of one central incisor slightly lingual to other central incisors without
rotation, and
iii. Placement of one central incisor slightly labial to and slightly longer than other
central incisor.
The central incisors should contrast sharply in size with the lateral incisors.
The Depth grounding should be done to the central incisors. It must dominate the
lateral incisors in their positions without the general curve of the anterior dental arch.
The purpose of this study by S Wolfart et. al., in 2006 was to evaluate the
subjective judgment (SJ) of patients on their own dental appearance and to correlate
the results with objective measurements (OM) of their dentition concerning the
appearance of the upper incisors. Seventy-five participants (30 men and 45 women)
with normal well-being were included in the study. In a questionnaire they judged the
appearance of their upper incisors. Furthermore, OM were evaluated by the
investigator with regard to the following points: (i) absolute length of the upper
central incisors, (ii) their length exposed during laughing, (iii) width-to-length ratio of
central incisors and (iv) the proportion between the width of the lateral and central
incisors. The subjective results were registered on visual-analogue scales. For the
objective results standardized photographs were taken. No gender dependent
differences could be found for the objectively measured parameters (median).
However, significant correlations between subjective and objective results could be
shown for men, but not for women.. The degree of satisfaction concerning
appearance of anterior incisors in accordance with golden standard values is higher
for men than for women.26
The purpose of this investigation by Sterrett JD in 1999 was to analyse the
clinical crown of the 3 tooth groups of the maxillary anterior sextant of the permanent
dentition of normal subjects with respect to (i) width, length and the width/length
ratios and (ii) determine if there is a correlation between tooth dimension or tooth
50
groups ratios and subject height .A maxillary impression was taken and poured in
yellow die stone. The widest mesio distal portion and the longest apical ±coronal
portion of the test teeth were measured. Gender, ethinicity and subject height were
recorded for each participant The mean coronal tooth width (mm)of males versus
females was CI:8.59 versus 8.06 , LI:6.59 versus 6.13 and CA:7.64 versus 7.15.The
mean coronal tooth length (mm) of males versus females was CI 0.85 versus 0.86, LI
0.76 versus 0.79 and CA 0.77 versus 0.81.A comparison between genders of the
width/ length ratios of the CI and LI were found not to differ, however the CA ratios
for females was significantly greater than for males .A positive correlation was found
to exist between tooth group width /height ratios within genders. No significant
correlation was found between any of the tooth dimensions or tooth groups ratios and
subject height.27
Fabiana Mansur Varjao in 2006 stated that selecting artificial teeth for
edentulous patients is difficult when pre-extraction records are not available. Various
guidelines have been suggested for determining the width of the maxillary anterior
denture teeth. This study was undertaken to evaluate the use of the nasal width as a
guide for the selection of proper width maxillary anterior denture teeth in four racial
groups of the Brazilian population. One hundred and sixty subjects (40 Whites, 40
Mulattos, 40 Blacks, and 40 Asians) were selected. Using a sliding caliper, the nasal
width and the intercanine distance were measured. The four racial groups showed a
weak correlation between the intercanine distance and the nasal width. The
correlation found between the intercanine distance and the nasal width was not high
enough to be used as a predictive factor. The relationship between natural tooth width
and artificial tooth width as predicted by the nasal width showed that the nasal width
method is not accurate for all the studied groups.28

Lateral incisor position.

Its rotation either hardens or softens the dental composition, by rotating the
mesial surface inward or outward respectively (Fig. 26.). The lateral incisors should

51
be positioned so that at least a portion is seen when the patient speaks seriously
(speaking line determination). 28

Fig. 26. Soft (S) and Hard (H) positions of the lateral incisors (Courtesy:Frush JP, Fisher RD.
Introduction to Dentogenic Restorations. J Prosthet Dent. 1955;5:586-595.)

The right and left lateral incisors should have asymmetric long axis. Either
rounding the incisal edge for feminine effect or squaring the incisal edge for
masculine effect can incorporate the sex.
The purpose of the study by Forrest R. Scandrett in 1982 was to evaluate the
following methods for predicting the width of the maxillary anterior teeth and central
incisors. They were inter-commissural width, interalar width, bizygomatic width,
sagittal cranial diameter, interbuccal frenum distance, philtrum width, and age. It was
hypothesized that two or more of these predictor variables would provide a better
prediction of maxillary tooth width than any of them individually. An irreversible
hydrocolloid impression of the maxillary arch was made with extra care to record the
buccal frena. All impressions were poured immediately in Class I dental stone. For
the width of the maxillary anterior teeth, the best model of predictor variables was
interalar width, intercommissural width, age, and interbuccal frenum distance. For the
left central incisor, the best model was interbuccal frenum distance and interalar
width. For the right central incisor, the best model was intercommissural width and
interbuccal frenum distance.29
Dr Ulhas E Tandale in 2007 conducted a study to determine whether a
relationship exists between the intercanthal dimension and four mesiodistal width
52
combination of the maxillary anterior teeth. Maxillary anterior teeth of 210 patients
were examined. The intercanthal distance was measured between the median angels
of the palpebral fissure. The mean widths of two central incisors, combined width of
the four incisors and combined width of six anterior teeth were intraorally determined
at their widest dimensions. Statistical analysis was performed to determine the
relationship between the inter-canthal distance and the four measurements of
maxillary anterior teeth. After the statistical analysis, it was found that biometric
ratios of 1: 0.271 and 1: 1.428 could be used to estimate the central incisor width and
the combined widths of the six anterior teeth, respectively. Within the limitation of
this study, the intercanthal distance can be used as a preliminary method for
determining the width of the maxillary anterior teeth during the initial selection of the
teeth for an edentulous patient.29
The cuspid position.
It should be carefully positioned so as to dominate the lateral incisor and to
complete the desired upward curve of the smiling line.
Maxillary canine may be placed labially in the dental arch, giving this tooth
considerable prominence. The canine must never be depressed at its cervical end.
Rather, its labial surface should be more or less parallel to the side of the face when
viewed from the front.30
The purpose of this pilot study done by Carl E. Misch in 2008 was to evaluate
the relationship between the vertical position of the maxillary central incisal edge and
the maxillary canine relative to the maxillary lip line in repose of dentate patients. For
the female group, average central incisor exposure in relation to the relaxed maxillary
lip line was 3.8 mm. In the 30- to 39-year olds (17 patients), the average was 4.1 mm,
in 50- to 59-year olds (12 patients), the average was 1.8 mm, in the male group, the
average central incisor exposure was 2.5 mm, mm. The average for the 30- to 39-
year-old group (20 patients) was 3.2 mm. For the 40- to 49-year group (18 patients),
the average was 2.4 mm and for 50 to 61 years (21 patients), it was1.4 mm. The
canine position for the female group average exposure was 0 mm, For the 30- to 39-
year old group, average exposure was 1 mm ,The 40- to 49-year-old group exposed
53
an average of 0.4 mm, for the 50- to 59-year old group, canine exposure was ±0.5
mm . The male average canine exposure was ±0.5 m, for the 30- to 39-year old group,
the average was 0.9 mm, the 40- to 49-year-old group exposed an average of 0.2 mm,
For the 50- to 59-year old group, average was ±0.9 mm. There was a large range of
maxillary central incisal exposure in relation to the maxillary lip line and could not be
used predictably to assess incisal edge position subjects. Therefore, it is suggested
that the average canine exposure dimension can be used clinically to assess anterior
incisor edge position when restoring edentulous patients.31
The objective of this study Irfan Ahmed Shaikh et. al., in 2011 was to
determine the relationship of intercondylar distance with maxillary intercanine
distance. A total of 250 dentate subjects fulfilling the inclusion criteria were selected.
Upper and lower arch impressions were taken. Vernier caliper was used to measure
the distance between the cusp tips of maxillary canines. Intercondylar distance was
measured using arbitrary face bow. The distance between the two condylar rods
measured in millimeters with vernier caliper. Every distance was measured three
times to ensure the accuracy and mean taken. It was concluded that Intercondylar
distance provides significant measurements for the selection of anterior teeth in
edentulous patient. 32
It should be abraded to convey the physiologic age of the patient in the dental
composition (Fig. 27.).


Fig. 27.Age interpretation by cuspid (Courtesy:Frush JP, Fisher RD. The

Age Factor in Dentogenics. J Prosthet Dent. 1957;7:5-13.)

54
 The three basic requirements of cuspid tooth position are,
a) The tooth should be rotated to show its mesial surface (Fig. 28a.)
b) The cervical end (not the tip) should be out (Fig. 28b.) and
c) Observed from the side, the long axis of the cuspid should be vertical (Fig.
28c.).

Fig.28a. The tooth should be rotated to

show its mesial surface

Fig.28b. The cervical end (not

the tip) should be out

Fig.28c. Observed from the side,

the long axis of the cuspid should
be vertical

Fig. 29.Difference in Tooth contour

55
 Fig.30. Mesiodistal width (Courtesy:Levin EI. Dental esthetics and the
golden proportion. J Prosthet Dent 1978;40, 244-252.)

Mandibular anteriors.

Most of the time maximum attention was given to the maxillary anterior six
teeth for achieving a pleasing smile line. Less attention was given to the
arrangement of mandibular anterior teeth. Irregularity in arrangement of these
teeth results in staggered, uneven incisal edges, similar to a metropolitan sky line.
Creation of a natural appearing mandibular "sky line" in reality is actually as
important as the smile line, since an individual tal ks considerably more than he
smiles.

With linear occlusion, mandibular anterior teeth, which are intended more for
esthetic than function, can be placed as follows to enhance the esthetics.
1) Grinding the incisor edges.
2) Rotating and overlapping the teeth to give an irregular appearance.
3) Creating asymmetry in the divergencies of the proximal surfaces of the teeth
from the contact points.
4) Creating slight diastema between the lateral incisor and the cuspid on the one
side.
5) Varying the direction of the long axis.
56
 One of the setup that appears natural and decreases artificial appearance, is the
one in which both the central incisors are forward and rotated mesially, one or both
lateral incisors are lingual to the arch curve and slightly longer than the adjacent
teeth, the mesial surface of the canines overlap the distal surfaces of the lateral
incisors.12
Lewis Lorton D, in 1981 in his study on aesthetic parameters of mandibular
anterior teeth stated that designing mandibular anterior fixed prostheses for good
aesthetics involves many factors. Factors which are, at least in part, functionally or
phonetically determined are degree of vertical and horizontal overlap, curve and
height of the teeth, anterior placement of the incisal edge, and incisal contacts. Design
factors which must be appreciated and manipulated by the dentist in his prescription
and in the fabrication techniques are overlap, incisal wear and facets, and height and
variety of contact area. It is these design factors which are crucial to the esthetic
success of a mandibular anterior fixed partial denture. When viewed from the
occlusal, the arrangement of the mandibular six anterior teeth was curved, 69.5%;
straight, 17.5%; and irregular, 13.6%. The contour of the mandibular anterior teeth
was generally unrelated to the shape of the maxillary arch. A straight line
arrangement of lower anterior teeth viewed occlusally is not a common occurrence
(17.3%) except when the maxillary arch is square (40%).23
In 1979 Louis Blatterfein et. al., in his study clearly showed that the
mandibular anterior teeth do play an important role in patient appearance. These teeth
were displayed in resting, smiling, and speaking facial expressions. The mandibular
anterior teeth were displayed to a greater extent that the maxillary anterior teeth in at
least half or more of the resting and speaking facial expressions. Also, a positive
relationship appeared to exist between visibility of the mandibular anterior teeth (in
the various facial expressions) and age and sex. An increase in the visibility of the
mandibular anterior teeth was found in persons 40 years of age or older. Men
displayed mandibular anterior teeth in facial expressions to a greater extent than
women.34

57
Artistic reflection.
It is the arrangement of the teeth to reflect the dentist's concept of what he
thinks appears natural for the patient.33 Maxillary anterior teeth may be positioned as
follows to be harmonious with the other facial features:
1. Place one central and lateral incisor parallel to the midline and rotate the other
central and lateral incisors slightly in a posterior direction.
2. Creating asymmetry for the maxillary right and left cuspids. Rotate one in a
more posterior direction than the other. Place the neck of one in a more labial
direction than the other.
3. Create the good smiling line by proper placement of maxillary posterior teeth
mesiolaterally in relation to the cheek. When the teeth are placed too far
laterally, the buccal corridor is eliminated, resulting in a harsh, ugly and toothy
appearance. This should be avoided.

The spaces.

Spaces between the anterior or posterior teeth are extremely effective in

increasing natural appearence arrangement of the teeth, but their size and position
must be artistically and hygienically formed otherwise they will become unsightly
repositioneries for food, bacterial plaques and calculus. The location of spaces should
be chosen carefully so as to maintain proper balance in the overall composition.
Diastema is between the anterior teeth and spaces are between the posterior teeth.

The rules that must be observed with spaces are as follows,

a) All spaces must be v-shaped to shed food (Fig. 31.)
b) A diastema between the central incisors is unsightly and should be avoided.
c) Diastema should be asymmetrically placed on either sides of the dental arch.
For e.g., if a diastema occurs between the lateral and central incisor on the right

58
 side of the arch, it should not be repeated between the lateral and central
incisor on the left side of the arch.
d) The width of the diastema should be controlled so as not to appear unsightly at
any instances. Diastemas which are too wide appearing as black holes
conversely, which are too narrow are difficulty to construct so as to shed food.

Fig. 31. The v shaped areas D are the proper self cleansing form of all diastemas
(Courtesy:Frush JP, Fisher RD. The Dynesthetic Interpretation of the Dentogenic
Concept. J Prosthet Dent 1958;8:558-581.)

Spaces are always placed between the posterior teeth. This allows additional
spillways for food through these spaces and creates additional cutting edges from the
marginal ridges. Grinding the proximal surfaces of the posterior teeth sharpens these
cutting edges.

Embrasure.
It gives freedom to the dental composition (Fig. 32) and differs from the
diastema or spaces in that it represents a divergence of the proximal surface of the
anterior teeth from the contact point. There is no separation of the proximal surface
since the contact areas are touching.

59
 Fig.32 . The arrows E point to the embrasures which add a sense of freedom to the
appearance of the dental composition (Courtesy:Frush JP, Fisher RD. The Dynesthetic
Interpretation of the Dentogenic Concept. J Prosthet Dent 1958;8:558-581.)

Golden proportion.

Golden proportion is the ratio that is found in nature i.e., in shells, plants
(sunflower head and veins of a leaf) and peacock feather, which gives the pleasing
appearance.
Width of the central incisor should be in golden proportion with its adjacent
teeth as seen from the front, in order to achieve this pleasing effect.
As the music is the study of the harmony of sound in space, so is the proportion
study of harmony of structures in space.
In 1973 Lombardi mentioned about the Golden proportion in a comprehensive
article. Leonardo da Vinci illustrated a dissertation on the golden proportion and
Kepler called it the Divine proportion. Later Rickets designed Golden Proportion
calliper.

60
Fig. 33. Divine proportions in face (Courtesy:Preston JD. The Golden Proportion Revisited. J
Esthetic Dent 1993;247-251.)

Fig.34. Golden proportion

61
 Fig. 35. Axial inclination Anterior , Posterior

Levin stated that "the width of the central incisor should be in golden
proportion to the width of the lateral incisor and that the width of the lateral incisor to
the width of the canine should also be in golden proportion as should the width of the
canine to the first premolar" (Fig. 33 and 34) 36 The axial inclination of both the
anterior and posterior teeth follow a definite proportion mimicking with the golden
proportion.(Fig. 35)

Width of the central incisor should be multiplied by the value defined as the
golden proportion, which is 0.618, or approximately 62%. The resultant width of
lateral incisor should be multiplied by 62% to give the width of the canine.

Mahesh P et. al., in 2012 in a study on 300 subjects found that,

1. Outer canthus to outer canthus width (OCOC width), intercommissural width
at maximum smile and interalar width at relaxed state are the three facial
measurements that showed higher percentage of coincidence with Golden
Proportion especially when combined mesio-distal width of mandibular 4
incisors were considered as basic unit.
2. Out of above three facial measurements, the outer canthus to outer canthus
width showed highest percentage of coincidence (93.65%). So, this facial
measurement can be used for the selection of combined mesiodistal width of
mandibular 4 incisors for denture patients. (Outer canthus to outer canthus
width, OCOC/ 4.24).37

62
Repeated ratio.
Lombardi described the use of a continuous proportion or repeated ratio, which
has been established between the width of central and lateral incisor and, is continued
in the ratio of the placement of the remaining teeth and spaces.38
So according to this, the proportion of the width of the central incisor and
lateral incisor should be consistent between the width of lateral incisor and the canine
and from the canine to the first premolar moving distally.

Recurring esthetic dental (RED) proportion.

Preston reported that the Golden Proportion defined by Levin to use 62%
proportion was found in relationship between maxillary central and lateral incisors in
only 17% of the casts of patients.39The idea of a continuous proportion or repeated
ratio as defined by Lombardi opens up the idea of using a continuous proportion not
necessarily limited to the 62% proportion. It can be 70%, 80% etc. (Fig. 36.). This
idea implies, however, that the ratio of the widths established between the central and
lateral incisors then must be used as one move distally. If the elements of both
concepts are combined, one derives what is known as Recurring Esthetic Dental
Proportion. So instead of having to accept the proportion already defined by the
width of the central and lateral incisors, the dentist can define his or her desired RED
proportion.

63
 Fig. 36. Different recurrent esthetic dental proportions with constant size central incisor (Courtesy:
Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent 1978;40, 244-252.)

A study by S Wolfart et. al., in 2006 evaluated the subjective judgment (SJ) of

patients on their own dental appearance and to correlate the results with objective
measurements (OM) of their dentition concerning the appearance of the upper
incisors. Seventy-five participants (30 men and 45 women) with normal well-being
were included in the study. In a questionnaire they judged the appearance of their
upper incisors. Furthermore, OM were evaluated by the investigator with regard to
the following points: (i) absolute length of the upper central incisors, (ii) their length
exposed during laughing, (iii) width-to-length ratio of central incisors and (iv) the
proportion between the width of the lateral and central incisors. The subjective results
were registered on visual-analogue scales. For the objective results standardized
photographs were taken. No gender dependent differences could be found for the
objectively measured parameters (median). However, significant correlations
between subjective and objective results could be shown for men, but not for women.

64
The degree of satisfaction concerning appearance of anterior incisors in accordance
with golden standard values is higher for men than for women.38

Buccal corridor and negative space.

Buccal corridor can be defined as the dark space that appears between the jaws
during laughter and mouth opening (Fig. 37). This dark space contributes to the
individualization of the dental composition that is projected by color contrast.

Fig. 37. (A)The buccal corridor present in the natural dental composition (B) Molar to molar
smile which is characteristic of a denture (Courtesy:Lombardi RE. The principles of visual
perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29:358-
381.)

Negative space is the space created between the buccal surface of the posterior
teeth and the corner of the lips when the patient smiles.39
It begins at the cuspid, and its size and shape are controlled by the position and
slant of the cuspid even though the actual corridor exists posterior to the cuspid tooth.
This lateral space result from the difference existing between the width of the
maxillary arch and the breadth of the smile have been described to be in golden
proportion with the anterior smiling segment.
The use of buccal corridor prevents the sixty tooth smile or the molar to molar
smile which is often characteristic of a denture. The buccal corridor is present in the
natural dental composition.

65
 These spaces not only represent a key factor in the harmony of the smile itself,
but also a factor of the harmonious proportionate relationship between the smile and
other facial features. Its inclusion in dentogenics accomplishes an added illustration
of reality.
The aim of this study Adam J. Martin et. al., in 2007 was to assess the impact
of various sized buccal corridors (BCs) on smile attractiveness. One female smiling
photograph, displaying first molar to first molar (M1 ± M1), was digitally altered to
produce (1) smiles that filled 84, 88, 92, 96, and 100 per cent of the oral aperture; (2)
second premolar to second premolar smiles (PM2 ± PM2) that filled 84, 88, 92, and
96 per cent of the oral aperture; and (3) smiles with asymmetrical BC that filled 88,
90, 94, and 96 per cent of the oral aperture. The 18 smiles produced were evaluated
by 82 orthodontists (70 males and 12 females) and 94 laypeople (40 males and 54
females). Orthodontists and laypeople rated smiles with small BCs as significantly (P
< 0.05) more attractive than those with large BCs. Orthodontists rated M1 ± M1
smiles as more attractive than PM2 ± PM2 smiles, whereas laypeople preferred PM2
± PM2 smiles. Age and gender did not significantly influence the impact of BCs on
smile attractiveness.38

Gradation.
When two similar structures are placed at different distance from the viewer,
the closest will appear the largest (Fig. 38.).

66
 Fig. 38. Gradation effect. (Courtesy:Lombardi RE. The principles of visual perception and their
clinical application to denture esthetics. J Prosthet Dent 1973;29:358-381.)

As the teeth pass posteriorly, the light is reduced and this gives a gradually
darker shade and therefore a smaller appearance. It also blurs the detailed features,
which increases the illusion of distance and therefore depth.40
Purpose of this study by Rubina Gupta et al in 2009 was to evaluate of
relationship between various anatomical landmarks and the occlusal plane in the
natural dentition that could be used for establishing the occlusal plane in complete
dentures. The study comprised of 100 dentulous subjects with all healthy permanent
teeth in normal arch form and alignment. Three instruments were custom-made for
the purpose: the occlusal plane analyzer to check the parallelism of the ala-tragus
lines, and the interpupillary line, the buccinators groove relator and the level analyzer
for the level of the linea alba buccalis with the occlusal plane. For the retromolar pad
area a metallic scale was used.
Within limitations of this study, it was observed that, only 13% subjects
showed occlusal plane parallel to the interpupillary line. The posterior reference point
RI&DPSHU¶VOLQHZDVPLGGOHSRLQWIRURIPDOHVDQGVXSHULRUSRLQWIRURI
females. Intraorally, 68% of subjects have the occlusal plane at the same level as that
of buccinators groove and 77% of the subjects had the occlusal plane at the middle
one-third of retromolar pad area. It was concluded that: the occlusal plane is parallel
WR&DPSHU¶VSODQHSRVWHULRUUHIHUHQFH point as the superior point of tragus in females
and middle point in males. The occlusal plane is not generally parallel to the
interpupillary line. Intra-orally, the level of buccinator groove is reliable, while
67
variations in retromolar pad area make it an unreliable landmark for orienting the
occlusal plane.41
This phenomenon of front-back progression is commonly used in architecture
to give an illusion of infinite depth and had been mastered in Greek monuments and
mosques in creating a perception of mystery and permanence.
The buccal corridor or lateral negative space between the buccal outline of
posterior teeth and the corner of the mouth helps in achieving the gradation effect in
progressively altering tooth illumination.
It requires the knowledge and the control of the principle of gradation, which
involves the perception of a progressive reduction in size from the most anterior to
the most posterior teeth in order to introduce changes of individual feeling into the
smile.
The manipulation of buccal corridor and the gradation effect, is an important
factor in allowing the prosthodontist to enhance the patient's personality.

Long axis.
Upon close examination of position of natural teeth, it must be noticed that
their long axis vary.42 So it should be exaggerated in the dentogenic restoration as an
artistic device (Fig. 39.).

Fig. 39. The variable long axes of teeth become accentuated with age. (Courtesy:Frush JP, Fisher
RD. The Age Factor in Dentogenics. J Prosthet Dent. 1957;7:5-13.)
68
Gum line.
Gum line at the cervical ends of the teeth should vary in height (Fig. 40, 41,
42,43) generally gum line should be formed .43
a) Slightly below the high lip line at the central incisors.
b) Lower than the central incisor gum line at the lateral incisors.
c) Higher than the central or lateral incisor gum line at the cuspid.
d) Slightly lower than at the cuspid, at the bicuspid, and variable for the bicuspids
and molars.

Fig. 40a. A variation of the levels of Fig. 40 b. A general guide for

contact points establishing the height of the gum line
of each tooth

Class I Class II
Fig. 41. Gingival height

Fig.42. Contact points Fig.43. Gingival zenith

69
Tooth matrix (denture base).
In dentogenic restoration, the esthetic considerations of the denture base lies in
the matrix of the tooth.43 This is the part of the denture base that is visible when the
patient speaks or laughs.

Interdental papilla.
Interdental Papilla forms the main part of the tooth matrix (visible denture
base). i.e. one-third of the total importance of the dental composition. The other
two-thirds are occupied by the tooth and tooth position.
The general rules for the formation of the interdental papilla are as follows:-
a) Papilla must extend to the point of tooth contact for cleanliness.
b) The papillae must be various lengths.
c) The interdental papilla must be convex in all directions.
d) The papillae must be shaped according to the age of the patient and they are
classified as young, middle-aged (average) or old aged.
e) The papilla must end near the labial face of the tooth and never slope inward to
terminate toward the lingual portion of proximal surface.

The correctly formed interdental papilla accomplishes four definite purposes:

1) It creates a hygienic, self-cleansing inter-dental area. It should not be over-
accentuated with depressions, grooves, wrinkles, folds or any other shape,
which would defeat the smooth cleansing action of the lips or cheeks.
2) It is a complementary factor in age interpretation. The papilla becomes
progressively shorter and wider in the older dentogenic interpretation.
3) It determines the outline form of a tooth and makes the two dimensional
outline form of a tooth incidental to other esthetic requirements, such as the
age interpretation in the papillae and the personality identification in the
sculptured form of the tooth. The proper shape of the papilla can change a
square tooth into a tapering tooth or an ovoid tooth.

70
 4) It brings a degree of color reflection to the interdental area, which creates the
illusion of a natural dental composition.

With the sex, personality and age factors firmly in mind and with the latitude
already achieved by asymmetric spacing and arrangement of teeth, studies have been
done for the possible unconventional treatment of the visible plastic base.
Denture base can be made slightly convex, instead of flattening or concaving
the acrylic resin between the teeth, Two things can be achieved by doing this; Firstly
one the standard crevice or bacterial repository can be eliminated and the second by
lowering the visible papillae it is possible to heighten the natural effect still further.
We should not copy diseased or unsighty natural gingival contour however; we
should reproduce that which is pleasing in nature. So conditions like, spaces beneath
contact areas may be present in periodontally involved natural dentition should not be
duplicated, Deep festooning or depressions accentuating root prominences should be
avoided.

Lingual cutaway.
It is a groove in the lingual interdental surface, which begins at the contact
points of the teeth if they are together or at the tip of the interdental papilla if there is
a diastema, it widens and deepens according to the natural divergence of the lingual
proximal tooth surface. It fades away into the palatal surface of the denture.45
The purpose of lingual cutway is that when the food is incised, it will sweep
through the polished channel and keep the area clean. It also prevents an unnatural
exposure of plastic.

Labial and buccal denture base contour.

Natural base contour should be convex, vertically, from the denture border to
the tip of the interdental papilla in the anterior region. This necessitates a rather
modest thickness of the border of the labial flange from buccal frenum to buccal
frenum and eliminates the distortion of the muco-labial fold, which appears too often
71
as a bulge underneath the nose. A thickened anterior border of the wax occlusion rim
distends the lip unnaturally outward and upward and should be prevented because
this would disturb the proper recording of the low lip line.

Stippling.
The surface of natural attached gingiva appears rough when it is wiped dry.
The stippled effect is produced on the denture by the use of a stiff-bristled toothbrush,
trimmed to one shortened cross-row of bristles so that its application can be well
controlled. It can be made at the end with a no ½ round eccentric bur.
Stippling causes an uneven light refraction, which is an important factor
contributing to naturalness. The result will be amazing and gratifying beyond all hope
and expectation. The interdental papillae, which are tear-drop shaped sheds food
particles more efficiently than high, sharp, depressed inter-proximal spaces. By doing
this difficult foods, such as bits of lattice, corn skin, a apple rinds could be swept off
the base with a flick of the tongue as easily as breathing. It was a simple application
of high school-physics, a rubber suction cup will stick tenaciously to a smooth
surface, it is impossible to make the same cup adhere to concrete. So stippling helps
in breaking up light reflection as well as to prevent adherence of food, but it should
never be done in areas of attached gingival near the necks of the teeth.45
Characterization for esthetics of the denture base beyond the visible portion is
an impractical waste of time and effort. The stippling terminates just posterior to the
lost tooth in the arch. Irreversible hydrocolloid impressions were excellent source for
guidance in contouring.

Characterization of denture base.

An illusion of reality can be further created in artificial dentures by
characterization of denture base. By the production of the tissue contour and
simulating the anatomical characteristics of oral mucosa with various strains in a
denture base, a life-like restoration can be obtained.

72
 As early as 1951, Earl Pound, showed that artificial dentures can be made to
appear very natural by proper contouring and incorporating colour variations in the
denture base. The manufacturers of denture base resin were quick to react to this
suggestion and they incorporated red nylon fibers to the polymer powder to break the
monotony of the denture base resin as well as to give an effect of capillaries in the
denture base.
Characterization as described by Rajeev Srivastava in 2010 in his article is a
procedure in which the character or collective qualities of a person are introduced in
the complete denture, either by modification of teeth or denture bases, to make it
appear more natural for that particular person. Characterization of the complete
dentures is necessary to give the dentures a life like appearance, to make it appear
more natural. This paper reviews various principles in an effort to produce a natural
appearing denture like characterization of the denture bases, indication for
characterization of denture base, ideal requirements of denture base tinting materials,
various techniques for using tints etc.46
Deep (red) tones are seen in the mucobuccal fold, frenum, interdental papilla
and rugae.
Pale (yellow) tones (tooth coloured resin) are found in root eminences. Neutral
(pink) tones are located on the labial and buccal surfaces in the fan shaped areas
between root eminences and diverge towards the mucobuccal fold.
Melanin pigment is found mostly in attached gingiva, interproximal papilla and
marginal gingiva as a regular band or as irregular spotty areas.
This article by Marie-Violainein Berteretche in 2012 proposes a systematic
approach to analyze and reproduce the gingival characteristics. This three-step
process involves the gingival display of the smile line, gingival pigmentation, and
gingival morphology. Different procedures like procure staining and postcure
staining using either polymethyl methacrylate resins and/ or composite resins can be
used to reproduce the gingival features. Recent research has led to the development of
light-curing microfilled composite resins such as Gradia Gum (GC America) and
Amaris Gingiva (VOCO). After polymerization of the denture base, the composite is
73
applied to the resin and then light cured at the lab in a dedicated chamber without
temperature ramp-up. These composite resins come in numerous shades and with
different flow properties. These innovative techniques make it possible to produce
KLJKO\HVWKHWLFFRPSOHWHGHQWXUHVIRUHGHQWXORXVSDWLHQWVSUHVHQWLQJZLWKD³JXPP\´
smile, and the results offer satisfactory long-term stability.47

Fig. 44.a Passive Fig44b.Active Fig. 44c. Laugh

Staining armamentarium.
Characterization stains are produced by various manufacturers. The kit consists
of five sets of stains:
1. Red stains
2. Yellow stains
3. Blue, brown or its combinations, to be used for melanin pigmentation.
4. One bottle containing neutral pink polymer and the other with nylon fiber.
These are mixed together for blending vascularity and capillary effect.

Commercially available stains.

Minute stains. These are the resin pigments suspended in a varnish dissolved
in butanone. Applied with fine paintbrush. Available in seven different colours. It is

74
best to apply stains after the denture has been processed and polished as they are
easily removed during polishing. They can also be applied at the chair side.
Kayon Denture Stains. The acrylic powders are shifted into the denture
mould and localized with monomer which is dispensed from a syringe. It is possible
using these stains to produce features of gingival inflammation, a pale pink colour
over alveolar prominence. They are especially useful in non-Caucasian patients, who
often have extensive melanin deposits, mainly in the attached gingiva with smaller
amounts in the free and marginal gingiva.
Dreve Lightpaint. In this, pigments are mixed with a light-sensitive
methylmethacrylate carrier to aid bonding to denture teeth and bases. The stains are
applied using a very fine paint brush and are cured on a light box.behind the tip of the
papilla.47

Application of stains on the denture base.

Basically there are two techniques of staining denture bases. One technique
advocates trial packing the denture with neutral pink acrylic resin with a plastic sheet
of cellophane or polyethylene between the teeth and the resin. (The usual procedure is
to place cellophane between the resin and cast). After separation of the flash halves,
one finds the acrylic resin well adapted to the edentulous cast. The surface of the
resin shows the external contour of the denture base with the anatomic reproduction
of the labial, buccal and lingual surfaces. A clean brush is wett with monomer and
staining procedure is carried out by dusting and wetting method. The stains and
monomer are supplied in plastic dispensing bottles. It is very important to control the
amount and rate of wetting and also to prevent the running of monomer to the
adjacent areas. For this purpose a small hypodermic glass syringe with 24 gauge
needle works quite well.
A layer of desired tone of stain is sprinkled and moistened with monomer. In
this manner a definite sequence is followed. Some prefer to moisten the section to be

75
stained first with monomer, then add the stained polymer, and later moisten it with
monomer.
The second technique advocates application of stains on the stone surface of
the flask. This procedure involves the sequential application of stains on the facial
surface of the dewaxed plaster mold prior to packing the mold with acrylic resin. The
results of staining cannot be visualized till processing and deflasking are completed.
Correction of any error is also not possible in this method. Repeated application of
monomer directly against the separating medium may cause plaster to adhere to the
denture base after processing is done.
1. Red tones are sprinkled for melanin to the marginal gingiva and papillae and
wetted carefully (1.5 mm thick, 3mm width).
2. Pale pink and yellow tones are placed over the root areas and moistened with
monomer.
3. A layer of light red tones is placed interdental areas of teeth.
4. A narrow strip of deep red and blue tones is placed (melanin) along the
periphery of the labial flange.
5. Basic shade of light pink powder are sprinkled all over the areas (to depth of 2-
3mm) and wet to complete the veneer.
This characterized veneer is allowed to stand for 10 minutes prior to packing
the rest of the mold, rewet with monomer every few minutes and covered with a sheet
of polyethylene to prevent evaporation. Later the mold is placed with denture base
resin giving two trial closures.

Characterization of denture base is of particular value in,

1. Subjects with active upper lip
2. Persons having prominent premaxilla
3. Persons with certain vocations such as theatrical performers, singers and
teachers.
4. Others who expose more of denture base during speaking and smiling.
5. Young edentulous persons.
76
Characterization of artificial teeth.

Brown stain around the necks of teeth simulates the stains due to smoking, tea
and coffee habits. White opaque stains represent hypoplastic areas and synthetic
fillings. Vertical hair line can also be reproduced in artificial teeth. These effects add
to the naturalness of the anterior setup. Several leading tooth manufacturers such
characterized anterior teeth by the dentist from pre-extraction records or from natural
molds. These are stained so that the teeth are personalized for the denture wearer.

Rugal reproduction.
A 0.003 gauge tin foil is placed over the rugae area of the edentulous cast and
adapted to it with a rubber pencil. The adapted tin foil pattern of the rugae form is
trimmed along its sides and kept apart. After the denture wax-up is complete, the
corresponding base plate area in the palate is cut away and the tin foil rugae pattern is
placed over the palatal window. Soft wax is used to align the rugae pattern to the rest
of the palatal surface. The edges are sealed with wax.

Cosmetic factor.
It involves personal grooming When a person drives neatly and keeps generally
well groomed, the dentist should arrange the artificial teeth in positions that will
complement their efforts.48 However, it is ill advised to select delicately curved teeth
of matching hues and arrange them in a pleasing contour for the women who uses no
cosmetics and does not manicure her nails or keep her hair well groomed. Likewise
it is inadvisable to strive for refinement in the arrangement of artificial teeth for the
man with bushy, unkempt eyebrows and hair and with dirty or unpressed clothing.
Teeth would not harmonize with their setting and would therefore appear more
artificial.49

77
THE PRINCIPLES OF VISUAL PERCEPTION AND THEIR
CLINICAL APPLICATION TO DENTURE ESTHETICS

³+XPDQEHLQJVUHSUHVHQWWKHVHQVLWLYHYHFWRUWKDWJLYHVOLIHWRHVVHQWLDOEHDXW\´
This was said by Leonardo-da-Vinci which meant that esthetics is a phenomenon of
intellect. The process of perception is an organisation of sensory data which are
brought to the intellect where an answer is developed in combination with the results
of previous experiences or beliefs that are unconsciously interpreted. This is what is
known as percept.49

Composition.
The study of the relationships existing between objects made visible by contrasts
in colour line and texture is called composition.50:H µVHH¶ RQO\ EHFDXVH WKH H\H
differentiates. It can differentiate only if contrast exists in the situation being viewed.
As the contrast decreases the visibility decreases.

Unity.
The prime requisite of composition is unity.51 8QLW\PHDQVµRQHQHVV¶8QLW\LQ
the ordering of the parts of a composition to give the individual total effect of the
whole.
Unity exists in two types ± Static and Dynamic unity. Static unity is exhibited
by such structures as regular geometric shapes like snow/lakes and crystals. Plants
and animals are dynamic unities. The static structures are fixed without motion, the
dynamic are a crescendo approaching a climax.

78
 Fig. 45. Static and Dynamic unity

Cohesive and segregative forces.

Cohesive Forces. Elements that tend to unite a composition are cohesive
52
forces. A border is a cohesive force, also arrangement of elements in a definite form
or according to a principle.
Segregative Forces. Segregative forces must be introduced into the dental
composition to produce dynamic unity. Segregative forces are opposite of cohesive
forces. Unity with variety is necessary to make the design effective because although
the elements must be bound together in an organic whole they must be bound
together in an interesting manner.
+RJDUWK¶VOLQHRIEHDXW\KDVEHHQDQRXWVWDQGLQJH[DPSOHRIXQLW\ZLWKYDULHW\
(Fig. 46.). It is a line inscribed around a cone. The line is never the same at any
point along its course yet it never leaves the surface of cone.

Fig. 46. +RJDUWK¶VOLQHRIEHDXW\(Courtesy:Lombardi RE. The principles of visual perception and their
clinical application to denture esthetics. J Prosthet Dent 1973;29:358-381.)

79
Dominance.
Dominance is the prime requisite to provide unity. One colour, shape line must
dominate and others must be subservient. One tooth must dominate the anterior tooth
arrangement by virtue of its size. The central incisor is the logical choice. The
mouth is the dominant feature of the face. It dominates by virtue of its size, its
mobility and psychic associations with which it is involved.
The dominance of dental composition may be increased by making it more
visible. Increasing the mold size, using lighter teeth, placing the teeth farther
anteriorly, and increasing the exposed gingivo-incisal length are all methods of
increasing the exposed gingivo-incisal length. For a patient of soft personality of
µPRXV\¶ colouration with average facial features and with an average amount of tooth
area exposed mouth dominance may be achieved by minimizing the above factors.
For a patient of strong personality, striking features and brilliant coloration all or part
of the above procedures may be restored to bring mouth to its dominant role in the
facial composition.

Preplanned esthetics.
The preceding discussion provides enough information for preplanning the
esthetic design or tooth space allocation of the proposed denture. 21Bearing in mind
the evaluation of the patient as a being an analysis should be made of the shape of the
mouth. Important features to be considered are width and height, the location of
commissures in smiling position. Because the immediate frame of the area to be
occupied by dental composition is provided by the lips, the edentulous mouth may be
regarded as a blank space of irregular outline in which the dental composition will be
made. Because most of space is shown in the wide smile position it is this space that
should be considered. All decisions made in regard to tooth selection and placement
should be made on the basis of the features of this space and the evaluation of the
patient as a being.
There are very few dentitions that cannot be made more attractive by minor
alterations. When an immediate denture is made, the existing dentition should be
80
subjected to analysis to find the minor modifications that can be made to bring the
resulting denture into closer agreement with the esthetic factors involved.

Requirements of an esthetic upper denture.

An esthetic upper denture requires that its dental composition exhibit all the
mentioned qualities. Not all anterior teeth must be of similar widths. Dominance
must be exhibited by using a central incisor of sufficient size to dominate the
composition. Teeth must not be set on the static curve of a circle but on a dynamic
OLQHVLPLODUWR+RJDUWK¶VOLQHDQGWHHWKPXVWEHVHWZLWKUHJDUGWRDUHSHDWHGUDWLRWR
provide unity with variety. The teeth must be modified to harmonize with the
SDWLHQW¶VDJHVH[DQGSHUVRQDOLW\WRSURYLGHVXEMHFWLYHXQLW\9DULHW\RIVKDGLQJPXVW
be provided. The lines provided by the matrix must not be straight. The composition
must be placed in a natural position.
All other esthetic factors must be analyzed after the teeth are set up and viewed
in the mouth. Because the background directly affects the appearance, it is necessary
that all the teeth be set up for try-in. the dentist should set up the teeth while the
patient is present for these reasons and because of the wonderful educational
opportunity presented by this procedure.

Balance in denture esthetics.

One of the most important factors considered at try in is that of balance.
Balance suggests a steadiness that results when all the parts are properly adjusted to
each other, when no one part constituting force is out of proportion to another. A
synonym for balance is equilibrium.
Every act of seeing is a judgment. One can see nothing without also seeing the
immediate surroundings at the same time. Isolation is impossible. The mind is
constantly interpreting the relationships of objects to each other. The item viewed is
FDWDORJXHG LQVWDQWO\ DV ³LQ IURQW RI´ RU ODUJHU WKDQ RU D ³GLIIHUHQW FRORXU IURP´
cataloguing occurs without conscious thought. Even illusions are accepted until other
event proves them wrong (Fig. 47.).
81
 Fig. 47. Illusion: the vertical lines are of the same length.
Induced forces.
The disk on the corner of square exhibits the phenomenon of induced forces
(Fig. 48). There is a desire on the part of the beholder to see the disk more toward a
more stable position ± probably towards the centre. If another disk was added at
another corner the tension is relieved when the center of the pair of disks coincides
with the centre of square (Fig.49.). This tension is a part and parcel of the percept
itself as size, location or blackness. Since the tension has a magnitude and a direction
it may be described as induced force because nothing is actually pushing or pulling
on the disk. The force field of the disk is affected by the structural features of the
surface upon which the disk is moved.

Fig. 48. Lack of balance. The disk on the
square would look better in another position .
It is unstable. (courtesy: Frush JP, Fisher RD.
Introduction to Dentogenic Restorations. J
Prosthet Dent. 1955;5:586-595).
Fig. 49. Balance. The disk seems more
stable in this position (courtesy: Frush JP,
Fisher RD. Introduction to Dentogenic
Restorations. J Prosthet Dent. 1955;5:586-
595).

Structural map.

82
 The most stable position of the disk is the center. It seems to be more stable
along the cross-formed by the central, vertical and horizontal axis. The center is
established by the crossing of these four main structural lines. A structural map of the
force field of the square illustrates the direction in which the disk seems to be induced
to move towards the more stable positions (Fig 50.). A proposed structural map of
the force fields of the tooth area of mouth is illustrated (Fig 51.). The proper midline
location is necessary for stability. It may be conjectured that the attractive qualities
RIWKH³VPLOLQJOLQH´PD\GHULYHIURPWKHVWDELOLW\JDLQHGE\WKHOLQHVDSSUR[LPDWLRQ
to the diagonals of the structural map.

Fig. 50. Structural map(Courtesy: Frush JP, Fig. 51. A proposed structural map of the tooth area.
Fisher RD. Dentogenics : Its practical application. (courtesy:Frush JP, Fisher FD. Dentogenics:Its prac
J Prosthet Dent 1959;9:914-921) tical application. J Prosthet Dent 1959;9:914-921)

The induced forces principle answers the question whether the midline should
be placed in the middle of the head or the mouth. It should be placed at a point where
it should be stable and does not seem to move left or right. The midline need not be
measured. A long contemplative look at the midline will reveal if this stability exists.
The principle of illumination must also be considered when speaking of balance.
This merely says that when two objects are the same size the lighter one will appear
larger. The larger object has more visual weight. In denture esthetics the balancing
problem is complicated by the fact that patient sees the prosthesis only by looking at
the mirror and only rub a mirror image in which left and right are reversed. It is wise
for a dentist to consider try-in in a mirror along with the patient if misunderstandings
are to be avoided. The selection should be done under three types of lights. Colour
free fluorescent, incandescent and natural light.
83
Line in the dental composition.
In pure lines, the strongest relationship that can exist between two lines is a
perpendicular relationship because it exhibits the greatest possible contrast. The most
harmonious relationship that can exist between two lines is a parallel relationship
because it exhibits the least possible contrast.
The line relationship between adjacent teeth should be harmonious that is
striving toward parallelism and therefore harmony. The chief offender is usually the
line formed by the distal outline of lateral incisor, but the buccal surface of the first
bicuspid is very close to second. It is often necessary to reduce the distolabioincisal
contour and the incisal third of the distal outline of the lateral incisor to eliminate the
conflicting line. The neck of the lateral incisor may be kept out labially to minimize
the line conflict. The conflict offered by the bicuspid can usually be handled by
repositioning the tooth. The line formed by the labial outline of the cuspid is
especially important because when viewed from front it is a prominent line and is
close to the line formed by the lower lip as it curves upward toward the commissure.
It actually completes the smiling line. If the incisal edge is tipped lingually the line
formed by the labial surface of the cuspid is more nearly parallel to the line of lower
lip and exhibits a softer relationship. As the cuspid is tipped further labially at the
incisal edge, it becomes more perpendicular to the lip line and exhibits a strong
relationship.
At the smile position if the incisal edges of the anterior teeth parallel to the line
of the lower lip as in the smiling line, a harmonious relationship exists (parallelism).
A line need not be complete to be perceived. The perceptual factor of closure is
responsible. A series of data or incomplete lines can be perceived by mind as a shape.
The mind simplifies four dots become a square. It organizes its perception in the
terms of forms it recognizes. When the statement is made that the tooth should be set
in a certain type of line or curve, these are the factors that make it possible. The
incisal edges and cusp tips can create a line in the dental composition.
The occlusal plane is another critical line in the composition and must be
located in the proper position usually at the line of the composition and must be
84
located in the proper position, usually at the line of the commissures with the mouth
slightly open but at rest. Finally, the lines of the matrix at the gingival must be curved
to prevent a sin against reality.

Shade selection.
It is not the shade of the individual tooth that matters, it is the effect of the shade
as it contributes to the relationship between the total dental composition and the total
facial composition.48
Selecting the lightness or darkness of the teeth should correspond to the
complexion, hair, skin and eye colour. To improve the appearance of artificial teeth
incisor teeth should be lighter in shade than canines.
Study by Hallarman 56confirmed that canines are darker than central incisors, and
colour darkens with age. Women prefer lighter shade than men do. Strong personality
indicates the need for a "strong" tooth arrangement and therefore is one indicator for
a light shade.
It is in the selection of shade, it is not the shade of the individual tooth that
matters; it is the effect of the shade as it contributes to the relationship between the
total dental composition and the total facial composition. The important factors
which affect the selection of shade are personality, background, facial features, total
tooth area displayed and the amount of light reaching the teeth. The intrinsic
coloration and value of the shade are also important. All of these factors may be
weighed as to their demands on the lightness value of the shade to be selected. Shade
may be comfortably expressed as three gradients, with one gradient being average,
one above and one below.
The personality factor, for example, may be broken down as strong, average
and soft. A strong personality is one that is outgoing vivacious, dynamic, zippy or
full of energy. A weak personality would be the opposite. A strong personality
LQGLFDWHVWKHQHHGIRUDµVWURQJ¶WRRWKDUUDQJHPHQWDQGWKHUHIRUHLVRQHLQGLFDWRUIRU
light shade.

85
 Skin colours can be considered light average or dark. A dark skinned person
will not require a light shade, because the dark background will make the shade
appear lighter. In patients with dark skin tones the shades will have to be adjusted
downward. The element of age operates in the background factor because as the skin
wrinkles with age it reflects less light and therefore appears darker.
The facial features are important because it is these features with which the
dental composition must complete to play role in the face. Large, intense eyes are a
strong feature, large nose is a strong feature, dark hair is a strong feature. Light teeth
are indicated to make the mouth harmonize with the total facial structure. Features
may also be noted as strong, average or weak.
Total tooth area is important because as more teeth are displayed, the effect of
the composition is increased. This is not really the same as mouth size, because in
the smile position some very broad mouths show only a very narrow space inter-
labially and some smaller mouths show a large space interlabially. If only a small
amount of teeth are shown, the lighter shade may be indicated because the impact of
the mouth has to be created in a small area. For this reason, the smaller total tooth
area is considered as the strong gradient, while the larger tooth area is weak in its
demands for lightness of shade.
Light is the amount of illumination reaching the teeth and is affected by the
height of the lip line as well as thickness or fullness of lips. It is these heavy lipped
individual with a low lip line who require a lighter shade because being a darker area,
the shade is going to appear darker than its qualities would suggest. A lighter shade is
therefore required to reach the desired degree of harmony. The mouth with a reduced
amount of illumination on the teeth makes the strongest demand for lightness of
shade. This factor may be described as being dark, average or light.
The value is the essence of the shade previously described. All these factors
may be expressed briefly in a workable formula.
Wн&н^нddн>
с^ŚĂĚĞsĂůƵĞ
^

86
 Factors Affecting Harmony of Shade
Strength of
Total
indications
Personality Features Skin Tooth Light Shade
for lightness
Area
1. Weakest Soft Weak Dark Large Bright Dark.
2. Average Average Average Average Average Average Medium
3. Strongest Strong Strong Light Small Dark Light

Final critique.
Opinions of others, particularly the patient family or of the people considered
close associates are valuable aids to composition of teeth for esthetics. Position of a
daughter or a son's natural teeth can be an excellent guide when positioning the teeth
for parents.
At the try-in stage - Patient should be in standing position. Dental composition
should be criticized from a distance of 6 to 8 feet to obtain the over-all effect of the
smile. A good procedure is to insert the trial dentures for a try-in and have the patient
walk to the door of the operating room, turn around and smile. This provides the
advantage of a sudden impact of a pleasing or displeasing effect.
Patients should not be permitted to observe the trial dentition in the mouth until
the dentist is satisfied with the composition as it is created.
Since other people will see the appearance of the dentures most often during
normal conversation, patients should first observe themselves in this situation. The
patient is positioned 3 to 4 feet in front of large mirror with the trial dentures in the
mouth and given the opportunity to observe the denture during normal conversation
and facial expression. If possible, another adult member of the family should also be
asked to observe the patient during normal conversation.
Himanshu Aeran in his dynesthetic interpretation of esthetic in complete
dentures stated that function & esthetics are inseperable & interdependent factors of
prosthodontic success. The development & use of adequate function is the first step
followed by final refinement of prosthodontic service i.e. the dentogenic phase. The
87
dynesthetic and dentogenic concept like mold selection, midline, speaking line, smile
line, embrasures, interdental papilla and dentue base contours when effectively
applied, provides a more natural, harmonious prosthesis, which not only is desired by
patients, but also is a quality of care they deserve. Outstanding esthetics can be
achieved by simple guidelines, using tooth molds specifically sculpted for males and
females, arranging prosthetic teeth to correspond with personality and age and
sculpting the matrix (visible denture base) with more natural contours. By using
these principles, the right smile can be created, one that reflects personality and
character of the patient with all the benefits to health, spirit and mind that comes from
confidence.59

 

88
 CONCLUSION

The dentogenic concept is an esthetic philosophy. It considers gender, age and

SHUVRQDOLW\ WR UHVWRUH WKH SDWLHQW¶V GLJQLW\ DQG XQLTXH LQGLYLGXDOLW\ WKDW KDV EHHQ
missing in far too many prosthesis.

There are two worlds: the world we can measure with line and rule, and the
world that we feel with our hearts and imagination. The dynesthetic and dentogenic
concept, when applied, provides a more natural, harmonious prosthesis, which not
only is desired by patients, but also is a quality of care they deserve. Outstanding
esthetics can be achieved by simple guidelines; using tooth molds specifically
sculpted for males and females, arranging prosthetic teeth to correspond the sex,
personality and age and sculpting the matrix (visible denture base) with more natural
contours.
Every patient cannot afford the expense of full mouth or implant reconstruction
in an effort to avoid complete dentures. Should they become edentulous? By
employing dentogenic principles and concepts, it is possible to restore their dignity
and individuality.

Dentogenics is the guide and not a compulsion and thus our imaginative
perception eventually is given more freedom. However, the rules must be learned
first, and only practice, in their application will lead to success. Dentist must take full
advantage of all concepts to create dentures that restore the natural appearance of
their patients.

 

89
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