Dent 343 Lect 8_handout

Anterior Tooth Selection (contAnterior Tooth Selection (cont’’d) d)

& &

Anterior Tooth SettingAnterior Tooth Setting

Dent 343

Lecture No.8

Complete Denture Prosthodontics

Dr Esam Alem

November 24, 2009

Textbook Reference: Chapter 17

•• Anterior teethAnterior teeth are primarily selected to satisfy are primarily selected to satisfy

esthetic requirementsesthetic requirements

•• Posterior teethPosterior teeth are primarily selected to satisfy are primarily selected to satisfy

masticatory requirements / occlusionmasticatory requirements / occlusion

ANTERIOR TOOTH SELECTIONANTERIOR TOOTH SELECTION

GuidesGuides

•• PrePre--extraction records (photos, diagnostic casts, old xextraction records (photos, diagnostic casts, old x--rays)rays)

•• Existing dentures Existing dentures

•• PatientPatient’’s facial characteristicss facial characteristics

•• PatientPatient’’s sex, personality, ages sex, personality, age

•• Arch size and shapeArch size and shape

•• PatientPatient’’s preferencess preferences

ANTERIOR TOOTH SELECTIONANTERIOR TOOTH SELECTION Most manufacturers have followed the concept of dividing tooth Most manufacturers have followed the concept of dividing tooth

moulds according to the basic shapes of square, tapering, and moulds according to the basic shapes of square, tapering, and

ovoid. In general this technique for tooth selection is consideovoid. In general this technique for tooth selection is considered red

antiquated.antiquated.

Square Tooth Molds:Square Tooth Molds:With this angular With this angular shape, the central shape, the central

incisor is dominant incisor is dominant and the gingivoand the gingivo--incisal incisal curvature is moderate. curvature is moderate. The square facial The square facial

shape offers maximum shape offers maximum light deflection and light deflection and creates a bold effect.creates a bold effect.

Tapering:Tapering:Characterized by Characterized by rounded contours rounded contours

which taper towardswhich taper towardsthe cervical ridge. the cervical ridge. Moderate gingivoModerate gingivo--incisal curvature. incisal curvature.

Large triangular Large triangular incisor slightly incisor slightly triangular in shape.triangular in shape.

Ovoid:Ovoid:The teeth have a The teeth have a pronounced pronounced

gingivogingivo--incisal incisal curvature, which curvature, which tends to disperse tends to disperse the light the light

reflection and reflection and create a softened create a softened appearance.appearance.

1

A more valid approach to tooth selection was firstA more valid approach to tooth selection was first proposedproposed

as theas the DentogenicsDentogenics concept (concept (FrushFrush and Fisher). They and Fisher). They

integrated the selection of teeth into an esthetic system integrated the selection of teeth into an esthetic system

governed by the age, sex and personality of the patientgoverned by the age, sex and personality of the patient

a) a) Sex: Sex: malemale-- rugged with square teeth & bold central incisorsrugged with square teeth & bold central incisors

femalefemale-- pronounced curvatures, rounded point anglespronounced curvatures, rounded point angles

b) Personality: vigorous or delicateb) Personality: vigorous or delicate

““Personality toothPersonality tooth””--the maxillary lateral incisors vary the maxillary lateral incisors vary

more in size, form and position than any other toothmore in size, form and position than any other tooth

c) Age: c) Age: YoungYoung-- tapered, ovoid, rounded teethtapered, ovoid, rounded teeth

MiddleMiddle-- somewhere between young and oldsomewhere between young and old

OldOld-- square, sharp cornerssquare, sharp corners

Contemporary Mould Guide Design Contemporary Mould Guide Design Following the basic concepts of Following the basic concepts of DentogenicsDentogenics some mould some mould

guides have been designed that follow a more logical sequence guides have been designed that follow a more logical sequence

to anterior/posterior tooth selection. This organization gives to anterior/posterior tooth selection. This organization gives the the

dental professional a significant advantage over the other dental professional a significant advantage over the other

systems in that there is systems in that there is immediate recognitionimmediate recognition of the tooth forms of the tooth forms

and sizes.and sizes.

Anterior Moulds

Posterior Moulds

large

medium

lower

anteriors

soft bold

anteriors

anteriors

lower

lower

small

short

short

short

long

long

long

Non-anatomic Lingualized

Semi-anatomic Anatomic

small

medium

large

small

medium

large

Example: Example:

BlueLineBlueLine Mould Guide System Mould Guide System

((IvoclarIvoclar ®® VivadentVivadent))

2

Sequence of Anterior Tooth SelectionSequence of Anterior Tooth Selection

1. Size1. Size

Selection of an appropriate size is probably the most Selection of an appropriate size is probably the most

critical factor in anterior tooth selection. Many critical factor in anterior tooth selection. Many

methods and techniques have been advocated. Two methods and techniques have been advocated. Two

of the more popular concepts will be illustrated.of the more popular concepts will be illustrated.

2. Mould form2. Mould form

In general terms moulds are divided into In general terms moulds are divided into ““softsoft”” and and

““boldbold”” forms based on several morphologic forms based on several morphologic

characteristics based on works of Fisher and Frush. characteristics based on works of Fisher and Frush.

3. Length3. Length

Only of major concern when patient has significant Only of major concern when patient has significant

display of anterior teethdisplay of anterior teeth

4. Shade4. Shade

•Place a mark at the

junction of the commissure of the lips at rest

•This line represents approximately the distal

proximal surface of the canine

•Several manufacturers have specific guidelines for

this measurement that facilitate the selection of an

appropriate sized anterior tooth mould

3

Size using the Facial-meter

• Inter-alar width: In the majority of patients,

a proportional relationship exists between the width of the nose and the size of the

maxillary anterior teeth.

• Inter-canine width

(distal left canine – distal right canine)

= interalar width x 1.56 (- 1.6)

• The facial meter (Ivoclar Vivadent)

interprets this measurement and gives a suggested list of tooth moulds made by

the manufacturer that fit into the patient’s

individual inter-alar measurement.

Facial Meter measures widest dimension of nose and lists the

appropriate moulds into small, medium, and large categories.

Mould Form Selection

Based on tooth morphology a tooth mould can have soft or bold characteristics

softbold

Soft CharacteristicsSoft Characteristics

•• Rounded arch formRounded arch form

•• Rounded tooth cornersRounded tooth corners

•• Anteriors closely follow Anteriors closely follow the lower lipthe lower lip

•• Laterals overlap centralsLaterals overlap centrals

•• Smaller laterals and Smaller laterals and cuspidscuspids

•• Sharp caninesSharp canines

4

Bold CharacteristicsBold Characteristics

•• Angular outlinesAngular outlines

•• Larger laterals and caninesLarger laterals and canines

•• Square arch formSquare arch form

•• Centrals overlap lateralsCentrals overlap laterals

•• Blunt caninesBlunt canines

With natural teeth however often times we find bold characteristics

where one would normally expect

softer tooth forms and arrangements.

For example this patient has

several bold tooth characteristics

(square teeth, bold arrangement) that do not complement her

appearance.

This gentleman’s natural dentition demonstrates several

characteristics (bold centrals, rounded laterals, mesial overlap of

laterals, laterals shorter than centrals) that are thought to be

more soft or feminine.

There are no firm rules, however There are no firm rules, however

in general tooth forms are in general tooth forms are

selected primarily based on soft or selected primarily based on soft or

bold characteristics matched to bold characteristics matched to

the individual patientthe individual patient

Tooth Length Tooth Length -- estheticsesthetics

•• As mentioned before, length is important for those patientAs mentioned before, length is important for those patient’’s s

who have a significant display of anterior teeth.who have a significant display of anterior teeth.

•• We normally expect to see approximately 2/3 We normally expect to see approximately 2/3 –– 3/4 of the 3/4 of the

facial surfaces of the maxillary anterior teeth when the facial surfaces of the maxillary anterior teeth when the

patient smiles widely. However, the degree of display of patient smiles widely. However, the degree of display of

maxillary anterior teeth varies greatly between individuals.maxillary anterior teeth varies greatly between individuals.

•• An average An average ““high smile linehigh smile line”” is one where the patientis one where the patient’’s s

upper lip lies approximately 6upper lip lies approximately 6--7 mm above the 7 mm above the incisalincisal edge edge

of the maxillary wax rim when the patient smiles or laughs.of the maxillary wax rim when the patient smiles or laughs.

•• If a patient has an average If a patient has an average ““high smile linehigh smile line”” 7 mm above 7 mm above

the the incisalincisal edge, then an appropriate length of tooth to edge, then an appropriate length of tooth to

select for good esthetics would be: 7 x 3/2 = 10.5 mm select for good esthetics would be: 7 x 3/2 = 10.5 mm 5

Tooth Length Tooth Length –– resorption of residual ridgeresorption of residual ridge

•• In some cases the amount of residual ridge resorption will In some cases the amount of residual ridge resorption will

take precedence over the take precedence over the ““high smile linehigh smile line”” and esthetics and esthetics

when tooth length is concerned.when tooth length is concerned.

•• In patients who have had recent extraction, the residual In patients who have had recent extraction, the residual

ridges are large because ridge resorption has not ridges are large because ridge resorption has not

progressed significantly yet.progressed significantly yet.

•• When the maxillary anterior residual ridge is large then the When the maxillary anterior residual ridge is large then the

overlying occlusal rim will be relatively short and there will overlying occlusal rim will be relatively short and there will

only be limited height for the anterior teeth to be set. only be limited height for the anterior teeth to be set.

•• In such cases, shorter teeth are often selected to make In such cases, shorter teeth are often selected to make

setting easier without the need of trimming the root end setting easier without the need of trimming the root end

(ridge(ridge--lap) end of the artificial teeth.lap) end of the artificial teeth.

�� The principal colors in teeth are white, yellow, red, brownThe principal colors in teeth are white, yellow, red, brown

and greyand grey

�� Aim to Aim to harmonizeharmonize between color of the skin, hair & eyesbetween color of the skin, hair & eyes�� HarmonizingHarmonizing complexion with tooth color does NOT mean complexion with tooth color does NOT mean

using dark teeth with dark skin.using dark teeth with dark skin.

GuidesGuides

1.1. ComplexionComplexion

2.2. Hair colorHair color

3.3. Eye colorEye color

4.4. AgeAge

5.5. Gender, personality & activityGender, personality & activity

6.6. Existing denturesExisting dentures

7.7. Patient desires Patient desires

8.8. Need to educate patientsNeed to educate patients

Shade Selection

Check the shade of the patientCheck the shade of the patient’’s existing denture and discuss their s existing denture and discuss their

desires with respect to the tooth shade. Ask patient whether thdesires with respect to the tooth shade. Ask patient whether they ey

would prefer the same shade or a shade that is lighter or darkerwould prefer the same shade or a shade that is lighter or darker..

•• Place the guide up against the patientPlace the guide up against the patient’’s face and select a s face and select a

shade that blends with their skin tone, hair color and sclera/eyshade that blends with their skin tone, hair color and sclera/eye e

color.color.

•• Once you have selected a color allow the patient to view it Once you have selected a color allow the patient to view it

against their lip with a mirror. Obtain patient approval. against their lip with a mirror. Obtain patient approval.

The importance of evaluating the patientThe importance of evaluating the patient’’s existings existing

denture and the patientdenture and the patient’’s input can not be overstated.s input can not be overstated.

Probably one of the most important factors for selecting Probably one of the most important factors for selecting

anterior teeth is the careful analysis of the patientanterior teeth is the careful analysis of the patient’’s s

existing dentures. Determine what they existing dentures. Determine what they likedliked and what and what

they they did not likedid not like about their denture. Balance that about their denture. Balance that

information with your perception of their existing information with your perception of their existing

denture.denture.

6

Acrylic Acrylic vsvs Porcelain Porcelain --Material considerationsMaterial considerations

•• Avoid selecting porcelain teethAvoid selecting porcelain teeth•• Porcelain teeth wear slowly and transmit occlusal forces to the Porcelain teeth wear slowly and transmit occlusal forces to the

residual ridges more aggressively, causing more rapid residual residual ridges more aggressively, causing more rapid residual ridge resorption (and flabby ridges) than acrylic teethridge resorption (and flabby ridges) than acrylic teeth

•• Porcelain teeth also do not bond chemically to the heat cure Porcelain teeth also do not bond chemically to the heat cure acrylic denture base like artificial acrylic teeth. The porcelaiacrylic denture base like artificial acrylic teeth. The porcelain n teeth require mechanical retention and pins to be retained in teeth require mechanical retention and pins to be retained in the acrylic denture base.the acrylic denture base.

•• Porcelain teeth are very hard and brittle. This makes them Porcelain teeth are very hard and brittle. This makes them difficult to adjust and trim. They are prone to difficult to adjust and trim. They are prone to ““chippingchipping”” when when a bur is used to trim them.a bur is used to trim them.

•• Superior esthetics: Some dentists consider porcelain teeth to Superior esthetics: Some dentists consider porcelain teeth to have a more natural appearance than acrylic teeth. However, have a more natural appearance than acrylic teeth. However, modern acrylic teeth are now manufactured with excellent modern acrylic teeth are now manufactured with excellent esthetics that often equal porcelain.esthetics that often equal porcelain.

Considerations:Considerations:

•• Pattern of maxillary ridge resorptionPattern of maxillary ridge resorption•• PhoneticsPhonetics•• Average valuesAverage values•• AlmagaugeAlmagauge (not available in our clinics)(not available in our clinics)•• PapillameterPapillameter (not available in our clinics)(not available in our clinics)•• Smile lineSmile line-- follow contour of lower lipfollow contour of lower lip•• Maxillary occlusion rimMaxillary occlusion rim

ANTERIOR TOOTH ANTERIOR TOOTH PLACEMENTPLACEMENT

Anterior Maxilla Pattern of ResorptionAnterior Maxilla Pattern of Resorption

•• Following extraction, resorption is from labial Following extraction, resorption is from labial

towards the lingual. Therefore anterior teeth should towards the lingual. Therefore anterior teeth should

NOTNOT be placed directly over the ridge.be placed directly over the ridge.

Phonetic ConsiderationsPhonetic ConsiderationsThe anterior teeth, tongue, and lips act as a part of the The anterior teeth, tongue, and lips act as a part of the

valvingvalving mechanism which modifies the flow of air to produce mechanism which modifies the flow of air to produce

speech soundsspeech sounds

Labial sounds: Labial sounds: ““pp”” ““bb””

�� if the lips are not supported properly by the teeth theseif the lips are not supported properly by the teeth these

sounds may be defectivesounds may be defective

Labiodental sounds: Labiodental sounds: ““ff”” ““vv””�� are produced by contact between the maxillary incisors are produced by contact between the maxillary incisors

and the posterior oneand the posterior one--third of the lower lip (vermillion border)third of the lower lip (vermillion border)

LinguopalatalLinguopalatal sounds: sounds: ““ss””, , ““shsh””

�� are made by contact between the tip of the tongue and the are made by contact between the tip of the tongue and the

palate at the palate at the rugaerugae area with a small space for the escape of area with a small space for the escape of

airair

7

Labial Labial ––dental dental ““FF”” & & ““VV”” soundssounds

The The ““ff”” and and ““vv”” sounds indicate sounds indicate

whether the whether the length (superiorlength (superior--

inferior position) of the upperinferior position) of the upper

incisorsincisors is correct.is correct.

The upper lip contacts the the The upper lip contacts the the

wetwet--dry line of the lower lip dry line of the lower lip

during speech production of during speech production of

““ff”” and and ““vv”” sounds.sounds.

If the upper anterior teeth are set If the upper anterior teeth are set

too long, then a too long, then a ““vv”” sound is made sound is made

when the patient means to make when the patient means to make

an an ““ff”” sound.sound.

Linguopalatal sounds: Linguopalatal sounds: ““ss””

The The ““ss”” sound is made by contact sound is made by contact

between the tip of the tongue and the between the tip of the tongue and the palate at the rugae area with a small palate at the rugae area with a small space for the escape of air.space for the escape of air.

If the space is too small a whistle usually If the space is too small a whistle usually results and if the space is too broad and results and if the space is too broad and

thin, the thin, the ““ss”” sound is replaced by the sound is replaced by the ““shsh””sound which sounds like a lisp. sound which sounds like a lisp. (1) This is affected by the shape and (1) This is affected by the shape and

thickness of the denture base in the thickness of the denture base in the palatal region.palatal region.

(2) The (2) The ““ss”” and and ““shsh”” sounds also indicates sounds also indicates whether the whether the (anterior(anterior--posterior position) of posterior position) of

the upper incisorsthe upper incisors is correct. If the patient is correct. If the patient

says says ““shsh”” when he means to say when he means to say ““ss””, then the , then the teeth may be too far forward.teeth may be too far forward.

Linguopalatal sounds: Linguopalatal sounds: ““ss”” –– closest speaking spaceclosest speaking space

(3) The (3) The ““ss”” sound also indicates whether the patient has adequate sound also indicates whether the patient has adequate ““freeway spacefreeway space””

or or interocclusalinterocclusal clearance. clearance.

When we speak, our upper and lower teeth do not normally contactWhen we speak, our upper and lower teeth do not normally contact each other. each other. (They only contact during function and swallowing).(They only contact during function and swallowing).

During speech, our teeth come closest together (1.0 mm) during tDuring speech, our teeth come closest together (1.0 mm) during the pronunciation he pronunciation

of the of the ““ss”” or or ““sibilantsibilant”” sounds.sounds.(They also come close together during (They also come close together during ““chch”” and and ““jj”” sounds). sounds).

During pronunciation of all other sounds, the space between the During pronunciation of all other sounds, the space between the upper and lower upper and lower teeth is larger than this.teeth is larger than this.

That is why we call the 1.0 mm space between the upper and lowerThat is why we call the 1.0 mm space between the upper and lower teeth during teeth during

speech the speech the ““closest speaking spaceclosest speaking space””

If we donIf we don’’t give the patient enough t give the patient enough ““freeway spacefreeway space”” during during ““jaw relation recordsjaw relation records””, , then the patientthen the patient’’s denture teeth will start hitting each other when the patient s denture teeth will start hitting each other when the patient pronounces the pronounces the ““ss”” sound.sound.

Maxillary incisal lengthMaxillary incisal length

On the average the On the average the

length of the maxillary length of the maxillary

central incisor is 22mm central incisor is 22mm

measured from from the measured from from the

labial sulcus adjacent to labial sulcus adjacent to

the labial the labial frenumfrenum..

Average Value Positions

8

Labial incisal positionLabial incisal position

On average the distance On average the distance

from the center of the from the center of the

incisal papillae to the incisal papillae to the

labial surface of the labial surface of the

central incisor is 8central incisor is 8--10 10

mm. This average mm. This average

influenced by the age influenced by the age

and gender of the and gender of the

patient.patient.

FemaleFemale

Young 8Young 8

Middle 7Middle 7

Old 6Old 6

MaleMale

Young 6Young 6

Middle 5Middle 5

Old 4Old 4

Average Value Positions

8

Almagauge

The Almagauge is a unique tool that records the incisal

length and labial position of the patient’s existing anterior denture teeth. This information can be transferred to the

dental lab to facilitate the positioning of the wax-rim.

•• The measurements can them be used to help guide The measurements can them be used to help guide

the initial contour of the wax rim.the initial contour of the wax rim.

Papillameter

Is a tool that measures the length of the patient’s lip in

relationship to the incisal papillae

9

Rest the flat platform

inside the mouth and up against the incisal

papillae.

Record the distance at

rest and during a smile. Communicating

this information to the

laboratory aids in the fabrication of the

maxillary wax rim length.

Smile LineSmile Line•• follow contour of lower lipfollow contour of lower lip

•• avoid reverse smile lineavoid reverse smile line

•• young female has greater curvature of smile lineyoung female has greater curvature of smile line

•• older males have less curvature of smile lineolder males have less curvature of smile line

Male

Female

Reverse curve

Greater curvature

Lesser curvature

Maxillary Occlusion RimMaxillary Occlusion Rim�� The position for the anterior denture teeth has been The position for the anterior denture teeth has been

initially established during the clinical adjustment of the initially established during the clinical adjustment of the

maxillary occlusal rim. maxillary occlusal rim.

�� If the rim has been properly modified to provide adequate If the rim has been properly modified to provide adequate

lip support and proper phonetics it can now serve as a lip support and proper phonetics it can now serve as a

guide to the actual placement of the denture teeth.guide to the actual placement of the denture teeth.

10

Setting Anterior TeethSetting Anterior Teeth

Lip SupportLip Support

The need for lip support from The need for lip support from

the teeth and denture flange the teeth and denture flange

varies depending upon the varies depending upon the

degree of ridge resorption.degree of ridge resorption.

In general, the In general, the

upper lip gets upper lip gets

its support from its support from

the teeththe teeth, not the , not the

denture flange. denture flange.

Phonetic Determinants of Phonetic Determinants of Anterior Tooth PositionAnterior Tooth Position

Clinically determined by the assessment of the Clinically determined by the assessment of the dynamic position of dynamic position of ““teethteeth”” during speech utilizing wax during speech utilizing wax occlusion rims and wax trial denture setocclusion rims and wax trial denture set--upup

““FF”” and and ““VV”” positionposition ““SS”” positionposition

•• Note the relationship Note the relationship between the incisal edge between the incisal edge to the wet line to the wet line (vermillion border) of the (vermillion border) of the lower lip when the lower lip when the patient makes a fricative patient makes a fricative ““FF”” and and ““VV””sound.sound.

““FF”” and and ““VV”” positionposition 11

•• Note the maxillary to mandibular anterior tooth Note the maxillary to mandibular anterior tooth relationship during sibilant relationship during sibilant ““SS”” sounds.sounds.

•• The mandible travels down and forward to create a The mandible travels down and forward to create a small space between the maxillary and mandibular small space between the maxillary and mandibular incisors during the production of sibilant soundsincisors during the production of sibilant sounds

““SS”” positionposition

Esthetic Determinants of Anterior Tooth PositionEsthetic Determinants of Anterior Tooth PositionA typical esthetic display of the maxillary anterior teeth. TheA typical esthetic display of the maxillary anterior teeth. The

central incisors are aligned with the midline and the laterals central incisors are aligned with the midline and the laterals

and cuspids are elevated off the occlusal plane.and cuspids are elevated off the occlusal plane.

Setting the Maxillary Anterior Setting the Maxillary Anterior Denture TeethDenture Teeth

Materials and ArmamentariumMaterials and Armamentarium

12

Cast LandmarksCast LandmarksMark the casts indicating midline, crest of the ridge, and Mark the casts indicating midline, crest of the ridge, and

the midpoint of the retromolar pad. These landmarks will the midpoint of the retromolar pad. These landmarks will

be used to check your denture setup.be used to check your denture setup.

maxilla mandible

Incisalpapilla

midlineAnterior land area

Ridge crest

Retromolarpad

Anterior landAnterior land

MidlineMidline

Incisive Incisive

papillapapilla

Lines indicating the crest Lines indicating the crest

of the ridge of the ridge

Midpoint of retromolar padMidpoint of retromolar pad

Mark on land indicating the Mark on land indicating the

midpoint of the retromolar padmidpoint of the retromolar pad

Land

Setting the Maxillary Setting the Maxillary

Anterior Denture TeethAnterior Denture Teeth

13

The three landmarks used to determine the The three landmarks used to determine the plane of occlusion are :plane of occlusion are :

•• The midpoint of the retromolar pads bilaterally as The midpoint of the retromolar pads bilaterally as previously marked on the mandibular cast.previously marked on the mandibular cast.

•• The incisal edge of the maxillary central incisorsThe incisal edge of the maxillary central incisors To set the remaining To set the remaining

maxillary anterior teeth, maxillary anterior teeth,

a clear glass or plastic a clear glass or plastic

plate is positioned to plate is positioned to

represent the plane of represent the plane of

occlusion.occlusion.

Mark indicating 2/3 height of Mark indicating 2/3 height of

the retromolar padthe retromolar pad

Soften some baseplate wax and attach the other Soften some baseplate wax and attach the other

central incisor to the ridge lap portion of the maxillary central incisor to the ridge lap portion of the maxillary

central incisors and attach it to the record basecentral incisors and attach it to the record base

Central Incisors

The mesial of each tooth should be on the midline The mesial of each tooth should be on the midline

(arrow) and the incisal edge should be parallel to (arrow) and the incisal edge should be parallel to

and in contact with the occlusal plane.and in contact with the occlusal plane.

14

Viewed from the facial perspective, the maxillary Viewed from the facial perspective, the maxillary

central incisor is placed so that the long axis shows central incisor is placed so that the long axis shows

a slight distal (a slight distal (~5~5ºº)) inclination to the perpendicular. inclination to the perpendicular.

This inclination may change with the tooth mold; This inclination may change with the tooth mold;

e.g., if the centrals have a square shape the e.g., if the centrals have a square shape the

mesiodistalmesiodistal long axis may be perfectly long axis may be perfectly

perpendicular to the horizontal plane (perpendicular to the horizontal plane (~0~0ºº tilt)tilt)

When viewed from profile the When viewed from profile the

cervical aspect of the tooth should cervical aspect of the tooth should

be slightly depressed. Note that be slightly depressed. Note that

the incisal 2/3 of the central the incisal 2/3 of the central

incisors are perpendicular to the incisors are perpendicular to the

plane of occlusion. The overall plane of occlusion. The overall

long axis of the tooth is long axis of the tooth is proclinedproclined

~5~5ºº

In this particular patient, appropriate lip support was achieveIn this particular patient, appropriate lip support was achieved by placing d by placing

the labial surface of the central incisors on a curve coincidithe labial surface of the central incisors on a curve coinciding with the ng with the inner edge of the land of the cast (red line). This may vary, ainner edge of the land of the cast (red line). This may vary, and in many nd in many patients the incisors project more anteriorly, particularly in tpatients the incisors project more anteriorly, particularly in those with hose with

severe resorption of the premaxilla.severe resorption of the premaxilla.

Inner edge of the landInner edge of the land

Occlusal planeOcclusal plane

The maxillary lateral incisor should be positioned with a slightThe maxillary lateral incisor should be positioned with a slight

distal inclination (distal inclination (~10~10ºº)) and is usually and is usually ½½ to 1 mm above the to 1 mm above the

plane of occlusion. plane of occlusion.

Lateral incisors

When viewed in profile When viewed in profile

note that the lateral note that the lateral

incisor is positioned with incisor is positioned with

a slight distal inclination a slight distal inclination

(~10(~10ºº) in relationship with ) in relationship with

the central incisor.the central incisor.

Note again that the lateral Note again that the lateral

incisor is positioned slightly incisor is positioned slightly

above the plane of occlusion.above the plane of occlusion.

Lateral incisors

15

When viewed from the occlusal, the incisors follow When viewed from the occlusal, the incisors follow

the curvature of the wax rim.the curvature of the wax rim.

Lateral incisors

When viewed facially, the cuspid has a distal When viewed facially, the cuspid has a distal

inclination (inclination (~10~10--1515ºº)) from the perpendicular and the from the perpendicular and the

incisal tip touches the occlusal plane (arrow). incisal tip touches the occlusal plane (arrow).

Cuspids

““ToedToed--inin”” PositionPosition

Note how the cervical and incisal edges of the cuspid are Note how the cervical and incisal edges of the cuspid are

aligned vertically. The cervical margin is prominent. aligned vertically. The cervical margin is prominent.

Note that when viewed from the anterior, that only the Note that when viewed from the anterior, that only the

mesialmesial surface of the canine is visible. The distal is surface of the canine is visible. The distal is

usually not seen.usually not seen.

Cuspids

The cuspid has two planes on The cuspid has two planes on the labial surface the labial surface –– a mesial a mesial plane (1) and a distal plane (2). plane (1) and a distal plane (2).

When viewed from the anterior When viewed from the anterior only the mesial plane should be only the mesial plane should be visible.visible.

Cuspids

1

2

16

When viewed from the When viewed from the

occlusal the anterior teeth occlusal the anterior teeth

follow a curvature that follow a curvature that

follows the shape of the follows the shape of the

wax rim (= shape of the wax rim (= shape of the

underlying residual ridge).underlying residual ridge).

Note the inclinations of the anterior teeth.Note the inclinations of the anterior teeth.

Setting the Mandibular Setting the Mandibular

Anterior Denture TeethAnterior Denture Teeth

•• Vertical overlap Vertical overlap (1(1--2 mm)*2 mm)*

•• Horizontal overlap Horizontal overlap

(1(1--2 mm2 mm)*)*

•• No contact in centric No contact in centric occlusionocclusion

* When using occlusal schemes with bilateral balance, * When using occlusal schemes with bilateral balance,

the amount of vertical and horizontal overlap will vary the amount of vertical and horizontal overlap will vary

depending on condylar inclination, occlusal plane and depending on condylar inclination, occlusal plane and

esthetic and phonetic needs. esthetic and phonetic needs.

Patients with skeletal Class I relationshipsPatients with skeletal Class I relationships

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Why horizontal and vertical Why horizontal and vertical

overlap?overlap?

1.1. We desire to minimize the We desire to minimize the

forces applied to the forces applied to the

mandibular and maxillary mandibular and maxillary

anterior ridges in centric anterior ridges in centric

occlusion.occlusion.

2.2. Create the appropriate Create the appropriate

relationship of the maxillary relationship of the maxillary

and mandibular anterior teeth and mandibular anterior teeth

during the production of during the production of

sibilant sibilant ““ss”” speech sounds. speech sounds.

Patients with skeletal Class I relationshipsPatients with skeletal Class I relationshipsMagnitude of horizontal overlapMagnitude of horizontal overlap

In Class II patients the mandible In Class II patients the mandible tends to travel farther anteriorly in tends to travel farther anteriorly in

function than the typical Class I function than the typical Class I patient and consequently more patient and consequently more

horizontal overlap is necessary to horizontal overlap is necessary to

allow for this functional movementallow for this functional movement..

In contrast Class III patients often demonstrate little or In contrast Class III patients often demonstrate little or no anterior movement of the mandible during function. no anterior movement of the mandible during function.

Consequently, little or no horizontal overlap is Consequently, little or no horizontal overlap is developed in the set up.developed in the set up.

Class IClass I Class IIClass II

Class IIIClass III

As noted previously, during the production of sibilant As noted previously, during the production of sibilant

sounds the mandible travels down and forward and a sounds the mandible travels down and forward and a

space of about 1 mm is created between the maxillary space of about 1 mm is created between the maxillary

and mandibular incisors. and mandibular incisors.

““SS””

In most patients the labial In most patients the labial

incisalincisal 2/3 of the 2/3 of the

mandibular incisors should mandibular incisors should

be roughly perpendicular to be roughly perpendicular to

the occlusal plane.the occlusal plane.

Occlusal Occlusal

planeplane

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In the setup shown here, the initial vertical overlap chosen wasIn the setup shown here, the initial vertical overlap chosen was

1.0 mm and the amount of horizontal overlap was 1.0 mm. 1.0 mm and the amount of horizontal overlap was 1.0 mm.

Vertical overlap 1 mmVertical overlap 1 mm Horizontal overlap 1.5 mmHorizontal overlap 1.5 mm Horizontal overlap Horizontal overlap 1 mm1 mm

Horizontal overlap is measured from the maxillary Horizontal overlap is measured from the maxillary palatopalato--

incisalincisal line angle to the mandibular line angle to the mandibular labiolabio--incisalincisal line angle.line angle.

Horizontal overlap 1.0 mmHorizontal overlap 1.0 mm

Incisal angleIncisal angle

Occlusal planeOcclusal plane

The incisal angle varies The incisal angle varies

depending on the depending on the

magnitude of the vertical magnitude of the vertical

and horizontal overlap, the and horizontal overlap, the

arrangement of the arrangement of the

occlusal plane and the occlusal plane and the

condylar inclination. It is condylar inclination. It is

generally advisable to keep generally advisable to keep

the incisal angle to a the incisal angle to a

minimum in complete minimum in complete

dentures.dentures.

Vertical Vertical overlapoverlap

Position the mandibular anterior teeth. The lower anterior teethPosition the mandibular anterior teeth. The lower anterior teeth

““mirrormirror”” the angulations of their upper anterior counterparts. the angulations of their upper anterior counterparts.

Central incisors should be vertically perpendicular to the Central incisors should be vertically perpendicular to the

occlusal plane.occlusal plane.

The necks of the lateral incisors should be (The necks of the lateral incisors should be (~10~10ºº) distal from the ) distal from the

perpendicularperpendicular. .

The necks of the canines should be(The necks of the canines should be(~15~15ºº)) distal from the distal from the

perpendicularperpendicular. . 19

The vertical overlap should be 1.0 The vertical overlap should be 1.0

mm throughout the anterior region.mm throughout the anterior region.

In profile, note that the cuspid is In profile, note that the cuspid is

slightly inclined to the distal slightly inclined to the distal

whereas the lateral incisor is whereas the lateral incisor is

relatively vertical.relatively vertical.

The horizontal overlap should be consistent throughout the The horizontal overlap should be consistent throughout the

anterior region (1.0) mm.anterior region (1.0) mm.

From the anterior perspective the angulation of the From the anterior perspective the angulation of the

mandibular anterior teeth should be as indicated. mandibular anterior teeth should be as indicated.

Note that the cervical of the cuspids are prominent. Note that the cervical of the cuspids are prominent.

SETTING THE LATERAL INCISORS AND CUSPIDSSETTING THE LATERAL INCISORS AND CUSPIDS

The anterior teeth have now been The anterior teeth have now been

positioned. The final positions may positioned. The final positions may

be be adustedadusted during the waxduring the wax--trial trial

denture appointment. denture appointment.

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DENTURE ESTHETICS DENTURE ESTHETICS

& CHARACTERIZATION& CHARACTERIZATION

� The loss of teeth can have a devastating effect on the appearance of a face.

� Edentulism and its aesthetic consequences are not very well accepted in our society.

� Today, at any age, people have learned the importance of an attractive smile, and when the face is mutilated by tooth loss there is a high demand for optimal

replacement .

See with the Eye See with the Eye

Observe with the MindObserve with the Mind

Frush

Patient

Dentist Technician

It is important to listen to our patients. Only by doing so can we determine their character, and understand their aesthetic preferences.

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�� ImpressionsImpressions

�� Occlusal planeOcclusal plane

�� VDOVDO

�� COCO

�� Placement of Placement of anterior teethanterior teeth

Each step in constructing a denture has aesthetic consequences.

Let’s look at each of these points in some detail.



�� VDOVDO

�� COCO


Proper support of the cheeks and lips is obtained withcorrectly molded impressions.

-The The orbicularisorbicularis orisoris and other facial musculature are and other facial musculature are

supported by the alveolar bone and teeth. Loss of teeth supported by the alveolar bone and teeth. Loss of teeth

and resorption of the alveolar ridge results in facial collapse.and resorption of the alveolar ridge results in facial collapse.

--You cannot remove wrinkles which are a part of the skin You cannot remove wrinkles which are a part of the skin

aging process.aging process.

LIP SUPPORTLIP SUPPORT

Consideration of proper lip support begins at the border molding stage.If the border is not thick enough, as in this case, in which there has been considerable bone resorption, the folds of the cheeks are too “wrinkled”

and the lips appear too thin.

LIP SUPPORTLIP SUPPORT

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�� VDOVDO

�� COCO


Lombardi R. E. J.P.D. 1973Lombardi R. E. J.P.D. 1973

The teeth should gradually rise along the occlusal plane toward the

back to give an impression of distance, as in perspective drawings.

Look at the difference between a flat occlusal plane and a correctly aligned one.



�� VDOVDO

�� COCO


The vertical dimension of the face in occlusion is responsible for the harmony between the lower third of the face and the face as a whole.

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Patients with long-term edentulism undergo mandibular deformation,

taking on a progenic (pseudo class-III) appearance that cannot be

completely corrected with a denture.

Loss of VDO results in a more exaggerated class III occlusion

BeforeBefore

AfterAfter

LOSS OF VERTICAL DIMENSIONLOSS OF VERTICAL DIMENSION



�� VDOVDO

�� COCO


Inter-maxillary relations on the horizontal plane also influence the aesthetic result.

This patient has been wearing an old denture for a long time – note the insufficient vertical dimension of the face and protrusion of the mandible.

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Before

After

Note aesthetic improvement in lip posture and fullness of the lips.



�� VDOVDO

�� COCO


•• Denture esthetics demands artistic skill in addition to scientifDenture esthetics demands artistic skill in addition to scientific knowledgeic knowledge•• The best method of developing skills is by observing natural teeThe best method of developing skills is by observing natural teethth

Gingival ContourGingival Contour

FemalesFemales--delicatedelicate MalesMales--ruggedrugged

Tooth WearTooth Wear

MAXILLARY ANTERIOR TEETHMAXILLARY ANTERIOR TEETH

Individualized CharacterizationIndividualized Characterization1.1. With With ageage

�� grind grind incisalincisal edgesedges�� grind proximal contactsgrind proximal contacts

2.2. MasculineMasculine

�� angular outlinesangular outlines�� sharp lateral contourssharp lateral contours

�� larger laterals and canineslarger laterals and canines

3.3. FeminineFeminine

�� rounder outlinesrounder outlines�� smooth lateral contourssmooth lateral contours

�� smaller laterals and caninessmaller laterals and canines

4.4. Lateral incisorsLateral incisors““personality toothpersonality tooth””

�� females females -- labioversionlabioversion�� males males -- linguoversionlinguoversion


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Lateral RotationsLateral Rotations

DiastemaDiastema

IncisalIncisal WearWearLabial rotation of lat. incisorsLabial rotation of lat. incisors

Lingual rotation of lat. incisorsLingual rotation of lat. incisors


Crowding & rotationsCrowding & rotations DiastemasDiastemas

StainingStaining IncisalIncisal WearWear

MANDIBULAR ANTERIOR TEETHMANDIBULAR ANTERIOR TEETH

DENTURE BASE ANATOMYDENTURE BASE ANATOMY

�� The gingival heights of the various teethThe gingival heights of the various teeth

in the arch vary and should never be in the arch vary and should never be waxed straight across. This a common waxed straight across. This a common mistake made in denture festooning.mistake made in denture festooning.

�� The lateral is always shorter than the The lateral is always shorter than the

canine or central.canine or central.

�� The canine is always longer then the The canine is always longer then the

premolar.premolar.

•• Tooth CharacterizationTooth Characterization

•• Denture Base CharacterizationDenture Base Characterization

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•• GoldGold

•• AmalgamAmalgam

•• CompositeComposite

•• StainingStaining

TOOTH CHARACTERIZATIONTOOTH CHARACTERIZATION TOOTH CHARACTERIZATIONTOOTH CHARACTERIZATION--STAININGSTAINING

�� Staining kits may be used to further characterize denture teethStaining kits may be used to further characterize denture teeth

and make them more age appropriate. The most common and make them more age appropriate. The most common

areas to be stained are areas to be stained are incisalincisal edges, craze lines, edges, craze lines, interproximalinterproximal

contacts and the roots at the gingival level.contacts and the roots at the gingival level.

GINGIVAL CHARACTERIZATIONGINGIVAL CHARACTERIZATION

�� Acrylic of various shades can be used Acrylic of various shades can be used

to mimic the patients gingival coloration.to mimic the patients gingival coloration.

�� These colors are layered into the flask These colors are layered into the flask

prior to packing.prior to packing.

�� Some discoloration/yellowing of the baseSome discoloration/yellowing of the base

occurs as the denture base agesoccurs as the denture base ages.

•• Gingival tintingGingival tinting

GINGIVAL CHARACTERIZATIONGINGIVAL CHARACTERIZATION

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Dent 343 Lect 8_handout

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