Reconstruction of coronal anatomy in ceramic

restorations of the anterior teeth

Yoshimi Nishimura*

Very tooth in a natural dentition has its own Anterior Teeth Viewed From the
natomy, which, at first glance, seems to have Labial Aspect
lO connection with that of the other teeth,
"he reality is that although every tooth is spe- When examining the individual teeth in the
ifically designed for a certain job at a certain anterior region, the external anatomy of the
tte in the mouth, it also fits in harmoniously teeth can be divided roughly into five areas
/ith the dentition as a whole. This is because (Figs 1 and 2):
iie design of each row of teeth follows a spe-
ific set of norms and rules that takes into ac- The incisai edge
uunt each tooth's individual anatomy. Pros- The mesioincisal and distoincisal angles
leses can likewise be fabricated to blend in The contact areas
armoniously with existing dentition by fol- The contour line
iwing these same guidelines. The cervical line
Key elements when fabricating the restora-
on of an anterior crown are design and tooth
antour. It is critical to take note of the rela- The Incisai Edge
onship between the expanse and direction of
le ridges and grooves and to consider the an- The incisai edge is the straightcst in the cen-
tomic variations of the teeth that will be ad- tral incisor, because its mesial, central, and dis-
icent to the restoration. tal ridges all lie on almost the same level.
In this article, the anatomic variations of the Pronounced tapering begins and progresses in
iterior teeth (central incisor, lateral incisor, the lateral incisors and the canines as the dis-
mine), which are vital for esthetic considera- tal and mesial ridges of the incisai edge appear
3ns, are examined from the point of view of in increasingly lower positions in these teeth,
le dental technician. and a clearly distinguishable arrow-head
shape results (Figs 2 and 3).
Compared to the central incisor, the position
of the highest incisai elevation moves increas-
ingly toward the mesial part of the tooth in
the lateral incisor and canine. The horizontal
11-607, MÍ2JD, Ibarägi-stii, Osaka 567, ¡apar. distance between the transition from the mes-

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 1 Anterior teeth: {a) labial view, {b) incisai view, (L) palatal view, (li) cervical view.

contact surface
incisai edge

angular region

proximal
contour line

cuniatute of
the cervical line

Fig 2 Variations in anatomy of central incisor, lateral incisor, and canine. Note differences in incisai
edge, angular region, contact surface, cervical tapering, and cervical line.

Fig 3 Tapering of indsal shape

and enlargement of angular re-
gion.

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Fig 4 Contact surfaces; note shift in position

from incisai area to middle of crown. Surfaces
decrease in size so that a > b > c .

iolabial ridge to the incisai edge and between lateral incisor and canine. The shape of these
the transition from the distolabial ridge to the areas, which is initially elongated, gradually
incisai edge is longest in the central incisor shortens, following the same progression (Figs
and becomes progressively shorter in the lat- 2 and 4).
eral incisor and the canine. This is because the
ratio of the mesial and distal thicknesses to
the palatal and vestibular thicknesses grows, Contour Lines
leading to an increasingly tapered and
rounded shape. The labial silhouettes of the teeth show an in-
creasing cervical taper in the same pattern, be-
coming sharper from the central incisor to the
Mesioincisal and Distoincisal Angles lateral incisor and then to the canine. In addi-
tion, the mesial and distal sides of the teeth
The angular region grows progressively larger become increasingly asymmetric; specifically,
from the central incisor to the canine, assumes the labial concave contour becomes lower and
an increasingly rounder form proximally, and deeper distally. The resultant shape is doubly
increasingly tapers incisally (Figs 2 and 3). The curved (Fig 2).
mesial angle in all teeth is smaller and sharper
than the distal angle, while the distal angle is
characteristically rounder and larger, in addi- Curvature of the Cervical Line
tion, the angles become absolutely rounder
and larger as one moves from the mesial angle The cervical line is almost horizontal in the
jf the anterior incisor to distal angle of the ca- central incisor and gradually arches downward
line. The mesial angle of the central incisor is in the lateral incisor and canine.
sharpest and smallest, the distal angle of the The incisai embrasure exhibits a very sharp
rentrai incisor is slightly rounder and larger, angle in the center of the row of anterior teeth
md the mesial angle of the lateral incisor is and is smallest there. The angle becomes
?ven rounder and larger; this pattern contin- larger distally, both incisovertically and mesio-
les to the canines. distally. The incisai embrasure between the ca-
nine and first premolar is the largest and
roundest. This is caused by the tapering of the
"Contact Areas teeth, by the difference in angle characteris-
tics, and by the transposition of the contact
^he contact areas in the central incisor lie surface cervically. The cervical embrasure be-
nesially near the incisai edge and shift in- tween these teeth is large incisocervically and
reasingly to the middle of the crown in the narrow mesiodistally. Laterally, the embrasure

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 Nishlmura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

labial surface

transition surface

próxima i surface

Fig 5 Tootb outhne viewed from the incisai aspect. Compare labial, labioproximal transition, proximal,
palatoproximal transition, and palatal surfaces.

Fig 6 Progression of width:

strength ratio (ratio between the
mesiodistal and labiopalatai ex-
tensions of tooth); compared ivith
the central incisor, the labiopalatai
extension (thickness) increases
and the mesiodistal extension
(width) decreases in the lateral in-
cisor and canine.

becomes smaller incisovertically and widens ally becomes more clearly curved labially than
mesiodistally. This is caused by the displace- does that of the central incisor. At the same
ment of the contact zone to the middle of the time, the curvature becomes less pronounced
crown and by the increasing cervical tapering. (Fig 7) because of the curve characteristic and
the tooth anatomy, which is similar in the ad-
jacent zones surrounding the contact surfaces.
Incisai View of the Contour Lines The degree of tapering is slight and the pala-
tal surface broad in the central incisor, so that
When the teeth are examined from the incisai the tooth's cross section is asymmetric labio-
aspect (Fig 5), a change in the ratio between palatally. This cross section becomes increas-
the mesiodistal width and the labiopalatai ingly symmetric in the lateral incisor and
thickness is apparent; from the centra! incisor canine (Fig 8a). Conversely, the central incisor
to the canine, the labiopalatal thickness in- is more symmetric mesially and distally, and
creases as the mesiodistal width decreases pro- the other anterior teeth become increasingly
portionately (Fig 6), asymmetric in this aspect as the twisting of
the teeth becomes visible (Fig 8b).

The Labial External Anatomy

Lnterdental Embrasures
As a result of the changed ratio of width to
thickness and the differing shapes of the mes- In addition to the anatomy of the anterior
ial, central, and distal labial ridges, the labial teeth, the spaces created by this anatomy,
outline of the lateral incisor and canine gradu- known as interdental embrasures, are also im-

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Fig 7 Progression of the curvature characteris-

tic; compared with the central incisor, the curva-
ture increases in the lateral incisor and canine.

Figs 8a and 8b (Left) Incisai view of central incisor, lateral incisor, and canine; labial and palatal surfaces become in-
creasingly symmetric. (Right) Mesiodistal view of central incisor, lateral indsor, and canine; labial and palatal surfaces
become increasingly asymmetric.

Fig 9 Upper and lower interdental embra-

sures; angles of upper spaces enlarge so that
A<B<C, angles of lower spaces decrease so
that a < b < c . Angles change as a result of cer-
vical tapering and angle characteristics.

Fig 10 Incisai view of embrasures; labial em-

brasures grow larger so that A<B<C, and the
palatal embrasures grow larger so that c < b < a .

portant (Fig 9). These spaces have clearly de- from the central incisor to the canine because
finable angle characteristics both incisally of the curvature of the dental arch, and the
above the contact zones and cervically. angles of the embrasures formed by the pala-
Viewed incisally, the angles of the embra- tal transitional and contact surfaces, on the
sures formed by the labial proximal and con- other hand, become more acute in the same
tact surfaces become more and more obtuse progression (Fig 10).

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 Nishimura • Reconstruction of coronai anatomy in ceramic restorations of the anterior teeth

Fig 11 Proximal view of anatomic variations'

angles formed hy the labial and palatal surfaces
of the incisai region grow larger so that
C < B < A . Location of the maximum curvature
is displaced incisally on both the labial and pal-
atal sides in the lateral incisor and canine when
compared to the central incisor.

Coronal Anatomy Viewed From the

Proximal Aspect
When examined from the proximal aspect, the
crown exhibits a three-part structure consist-
ing of the incisai, middle, and cervical regions
(Figs 11 and 12).

The Survey Line

The boundary between the middle and cervi-
cal regions of the teeth is called the survey
line, and its position changes significantly
among the anterior teeth. The survey line
shifts in an incisai direction labially and palat-
ally from the central incisor to the canine, and
the external shape of the tooth, with the sur-
vey line as its vertex, expands following the
same progression.
The difference in development of the ridges
mesially and distally increases in the same
way, resulting in a similar increase in the
mesial slope of the survey line in these teeth.
Therefore, the difference in position of the
survey line distally and mesially increases in
the lateral incisor and canine when compared
to that in the central incisor.
Fig 12 Proximal view showing progression
of three-surface form; (D) distal surface, (M)
mesial surface.

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I A / \

L\
-—,~->H~^—•—^

ig 13 Cervical view of anatomic variations in the Fig 14 Cervical view of embrasures; their size increases
icisal region; the incisai edge is smooth in the central so that A<B<C.
idsor, the mesial and distal sides slope down, and the
liddle part of the crown becomes increasingly promi-
ent in the lateral incisor and canine.

rhe Angle Formed by the Labial and rounded and without a great deal of slope in
Mlatal Surfaces the mesial and distal parts. The angles become
sharper and the slopes greater in the lateral
Accompanying the change in the width- indsor and canine.
hickness ratio and the position of the survey
ine, the incisai angle formed by the labial and
jalatal surfaces becomes more obtuse. The po- Coronal Anatomy Viewed From the
lition of the indsal edge (the tip of the tooth) Cervical Aspect
gradually shifts in a labial direction palatally
rom the central incisor through the canine.
The Shape of the Incisal Edges

rhe Outline of the Labial Surface From the cervical aspect, the incisal edge of
the central incisor approximates a straight line
\s a result of the changes in the incisai angle (Fig 13). In the lateral incisor and canine, the
md the position of the survey line, the outline middle of the labial surface increasingly proj-
)f the labial surface, which is still relatively ects incisally toward the proximal surface (Fig
lat in the central incisor, becomes more and 14). The incisal region of tbe central indsor is
nore convex in the lateral indsor and canine. concave because of the grooves in the labial
Jimultaneously, the cervical region becomes surface. In the lateral incisor and the canine,
iroportionately larger and the midpoint moves the shape of the incisal region decreases as the
ncisally, as a result of which the size of the grooves of the labial surface disappear, and a
tidsal region becomes proportionally smaller. V-shaped groove can be found near the incisal
The angle formed through the middle and edge.
ncisal regions, whose vertex is created by the
urvey line, becomes sharper from the central
ndsor to the canine because the survey line The Embrasures
«dens labialiy and palatally, and the vertex
ies deeper in the body of the tooth. In the In the incisal region, the embrasures between
entrai incisor, both the angle between the cer- the lateral incisor and the canine are larger
ical and middle regions and the angle be- than those between the central and lateral in-
ween the middle and indsal regions are cisors (Fig 14),

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 Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 15 Photomontage of the contour image o!

the labial surfaces.

Fig 16 Cervical and labial surface ridges.

Fig 17 Variations in the proximally directi

progression of the labial surface ridges.

progressively lower both from tooth to tooth

The Progression of the Contour and from ridge to ridge, in the sequence cen-
Image of the Labial Surface tral, mesial, distal (Fig 15). In the labial surface
of the central incisor, the three ridges are
about equally thick, but the central ridge be-
The Ridges of the Labial Surface comes increasingly thicker than the other two
in the lateral incisor and canine (Fig 16),
The mesial, central, and distal ridges in the la- The external cervical taper becomes sharper
bial surface of the central incisor are virtually from the central incisor to the canine, which
the same height. In the lateral incisor and ca- causes the grooves in the labial surface to be-
nine, the initial positions of the ridges become come more slanted in the same way.

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Fig 18 Peaks of the survey line; note incisai

shift in the lateral incisor and canine. Sharp ta-
pering changes the U shape of the line to a V
shape, and the slope increases mesially and
distally.

Fig 19 Grooves of the labial surface and

V-shaped groove. Paralleling the relative de-
crease in the incisai region in the lateral incisor
and canine, the grooves in the labial surface be-
come smaller incisaliy. Also, the V-shaped
groove shifts incisaliy because of the incisai dis-
placement of the survey line and the decrease
in size of the incisai region. Compared to the
central incisor, the cervical end of the mesio-
distal V-shaped groove in the lateral incisor
and canine exhibits an increasing slope.

The initial positions of the mesial and distal and less visible as a result of the change in
ridges on the labial surface of the central inci- shape of the incisai edges and the increasing
sor illustrate the tendency to originate from a prominence of the cervical ridge (Fig 19).
lower position and run to the contact surface In the central incisor, the V-shaped grooves
in comparison with the lateral incisor and ca- (Fig 19) have mesially and distally similar
nine (Fig 17). These ridges in the teeth of shapes and are greatly extended incisaliy. In
young people are concentrated toward the the lateral incisor and canine these grooves
middle tip of the incisai edge, that is, toward become gradually more different. This is be-
the tapering. In addition, the more asymmetric cause of the development of the three-part
the tooth is (progressing from the central inci- form that accompanies the change in shape of
sor to the canine), the more the confluence of the incisai edges, the growing prominence of
ridges moves mesially. the cervical ridge, and the change in the sur-
vey line.
The initial position of the V-shaped groove
The Survey Eine, V-Shaped Groove, and shifts incisaliy in the lateral incisor and canine
Grooves in the Labial Surface because, as a result of the change in the three-
sided form, the incisai region becomes nar-
The survey line runs in the direction of the rower in these teeth. The end points of the
cervical ridge (Fig 18). In the central incisor, it V-shaped groove change along with the sur-
is more or less horizontal and located far to vey line. These points are located at practically
the cervical portion of the tooth. In the lateral the same height mesially and distally, while in
incisor and canine, the survey line is increas- the canine a steep slope is apparent between
the position of the mesial and distal V-shaped
ingly sloped from the mesial to the distal por- grooves. Specifically, the end of the mesial
tion and shifts incisaliy. V-shaped groove shifts cervically.
The grooves in the labial surface become less

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 20 Compared to the central incisor, the

concave line in the lateral incisor and canine
becomes more clearly visible.

Fig 21 Labial triangular area formed by a line

connecting the ridge positions dlstally and the
concave lines distally. The labial triangular area
narrows distally around the contact surfaces.
Note that the ridges in the labial surface be-
come constricted proximally.

Fig 22 Contour image of the anterior

teeth.

The Concave Line The Triangular Area of the Labial

Surface
The concave line is more clearly visible in the
lateral incisor and canine than in the central From the central incisor, the mesial and distal
incisor. It is high and flat mesially and low ridges shift downward and move increasingly
and deep distally, and this difference is in- toward the contact surfaces in the central ind-
creased toward the posterior teeth. The twist- sor and canine. The triangular area of the la-
ing of the teeth gradually becomes more bial surface is described by a line connecting
visible because of this configuration (Fig 20). the place where the ridge in the labial surface

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Fig 23 Mesial view of contour image of anterior teeth. Fig 24 Proximal view of lines of the contact and cervi-
cal areas; note progression of positions at which the
ridges in the labial surface cross. Contact areas shift to
the middle of the crown, and the cervical areas that
stand out maximally on the proximal surface become
lower from A to B to C and produce a flatter line.

bends toward the contact surface and a line The Grooves in the Proximal Surface
connecting the posterior distal concave line,
with the contact surface as its center. This area The external shape of the proximal surface in
becomes increasingly smaller in the lateral in- the lateral incisor and canine develops an in-
cisor and canine (Fig 21 and 22). creasingly rounded shape compared to that in
the central incisor. Also, the width-thickness
ratio changes as mentioned above. For this
The Contour Image of the Proximal reason, the groove in the proximal surface be-
Surface comes steadily broader and flatter posteriorly,
until it is nearly invisible in the canine.

The Contact Surface

The Ridges in the Labial and Palatal
Compared to the central incisor, the extension Surfaces
of the contact surfaces becomes smaller verti-
cally in the lateral incisor and canine because When examining the slope between the posi-
the contact area shifts to the center and simul- tion of the central ridge and the position at
taneously becomes larger labiopalatally as a which the ridge of the labial and palatal sur-
result of the change in the width-thickness faces meet, it appears that this slope becomes
ratio described above (Fig 23). progressively greater in the lateral incisor and
canine as compared to that in the central inci-
The Cervical Line sor (Figs 25a and 25b). This is true mesially as
well as distally, but is especially pronounced
From the central incisor, the cervical line runs distally.
progressively more horizontally in the lateral From the proximal aspect, the ridges in the
incisor and canine, because the ratio of the ex- labial surface mesially, centrally, and distally
tension labiopalatally to the extension mesio- are almost in the same position. From the cen-
distally (width-thickness ratio) becomes larger tral incisor to the canine, the central ridge in
(Fig 24). the labial surface protrudes more labially, and

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 25a Proximal view of incisal edge, cervical

line, and tubercle; the slope of incisal edge in-
creases in the lateral incisor and canine as the
cervical line and tubercle shift to the middle ol
the tooth.

Fig 25b Compared to the central incisor, the

distance between the point of taper and the in-
tersection of the grooves in the labial surface oí
the lateral incisor and canine progressively
increases.

Fig 26 Palatal view of contour image of ante-

rior teeth.

Fig 27 Palatal view of variations in the mesial and distal ric Fig 28 Palatal view of incisal edges; note grad-
of tbe anterior teeth. ual assumption of a shape approximating out-
spread wings whose angles become more obtuse
in the sequence A < B < C .

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oped central and secondary ridges. The central

and secondary ridges become increasingly bet-
ter developed and more cleariy visible in the
lateral incisor and canine (Figs 26 and 27). The
origination of the incisai ridge shifts distally
from the center in the central incisor to an in-
creasingly downward position in the lateral in-
cisor and canine. The ridge also takes on the
shape of a pair of wings spreading out distally
from the mesial region. Further, embracing the
secondary ridge of the palatal surface, the
ridge becomes constricted proximally (Fig 28).
Fig 29 Palatal view of incisai region and tuhercle; the
incisai region becomes smaller posteriorly, and the tu-
bercle expands upward.
The Cervical Region

The cervical region is shaped in such a way

that, with the concave line as a boundary, it
the mesial and distal ridges increasingly be- expands upward labially (Fig 29).
come constricted inward as the central ridge
develops better labially in the lateral incisor
and canine. As a result, more and more of the
lahial surface becomes visible when the teeth The V-Shaped Groove
are examined from the direction of the mesial
or distal contact surface. As is the case with the labial surface, a
The configuration of the ridges in the palatal V-shaped groove forms between the central
surface appears similar. While in the centia! groove of the palatal surface and the incisai
incisor the middle of the palatal surface shows groove. This V-shaped groove shifts incisally
a concave shape and the mesial as well as the from the centra! incisor to the canine, and, as
distal incisai ridges protrude palatally, the cen- a result of the change in the tubercle, the ter-
tral ridge steadily protrudes more palatally in minal point of the groove also shifts upward.
the lateral incisor and canine, and the mesial In addition, the shape and depth of the groove
and distal incisai ridges retrude in the same become increasingly visible because of the de-
progression. In addition, the tubercle expands velopment of the central ridge in the palatal
palatally, and the secondary ridge becomes surface and the secondary groove (Figs 26 and
clearly visible. For this reason, more of the 29).
palatal surface becomes visible in the lateral
incisor and canine.
The Incisal Ridge and the Concave Line
The Contour Image of the Palatal When the anterior teeth are examined from
Surface the palatal aspect, it appears that the distance
between the line connecting the initial posi-
tions of the respective incisal ridges with each
The Incisai Ridge other and the line connecting the respective
concavities with each other decreases in the
An examination of the outline of the palatal same manner as the labial surface (Fig 30).
surface shows that the central incisor has a The area that is created inside this pair of lines
well-developed indsal ridge and poorly devel- is called the palatal triangular area.

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 30 Palatal triangular area in the anterior

teeth, which is formed by a line connecting the
place where the incisai ridges become con-
stricted proximally and a line connecting the
distal concavities. This area narrows in the lat-
eral incisor and canine.

Fig 31 Incisai view of contour image of anterior teeth. Fig 32 Incisai view of progressive anatomic variation ol
mesial, central, and distal ridges in the labial and palatal
surfaces.

The Contour Image Viewed From lateral incisor and canine than in the central
the Incisai Aspect incisor.
Compared to those in the central incisor, the
mesial and distal ridges in the labial surface
increasingly exhibit a shape that enfolds the
The Ridges of the Labial Palatal Surfaces secondary ridge and bends off proximally in
the lateral incisor and canine (Fig 32).
When the outlines of the anterior teeth are ex-
amined from the incisai aspect, either the
mesial and distal ridges in the labial surface The Concave Line
appear to be protruding outward, or all three
ridges appear to be approximately the same The concave line in the cervical area assumes
(Fig 31). This is because the mesial and distal an increasingly gentle curve toward the center
ridges in the lahial surface of the central inci- and becomes narrower and more clearly rec-
sor are strongly developed and the central ognizable as a groove posteriorly in the ante-
ridge is weakly developed. rior teeth further from the midline. Also, the
The central ridges in both the labial and pal- distal concave line is located deeper and far-
atal surfaces are increasingly strongly devel- ther down than the mesial one in the same
oped and stand out more distinctively in the pattern.

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 CERAMIC RESTORATIONS

Fig 33 Labiocervical view of contour image of

anterior teeth.

Fig 34 Labiocervical view of labial surface

ridges; note area between the cervical and
inrisal regions becomes thicker in the lateral in-
dsor and canine.

Fig 35 Labial view of contours of the incisai

edges cf anterior teeth viewed from the labial
aspect; note external shape of the incisai edges,
V-shaped groove, and groove in the labial
surface.

The Contour Image Viewed From the outside, and the mesial and distal ridges
the Cervical Aspect widen incisally (Fig 34).

The Ridges in the Labial Surface The Cervical Ridge

When examining the central incisor from the Compared to its position in the central incisor,
cervical aspect, the cenhral, mesial, and distal the cervical ridge develops incisally in the lat-
ridges stand out about equally strongly, and eral incisor and canine. For this reason, the
the mesial and distal ridges are parallel (Fig incisai region becomes proportionately smaller,
33). In the lateral incisor and canine, on the and the grooves in the labial surface and the
other hand, ihe mesial and distal ridges in the V-shaped groove in the central incisor become
labial surface bend to the outside and widen less visible in the lateral incisor and canine.
proximally. As a result, the central ridge in the Also, the V-shaped groove shifts incisally, re-
labial surface exhibits a shape that projects to suiting in an incisai contour (Fig 35).

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

The Three-Dimensional Nature of

Crown Anatomy

Relationship of the Developmental

Angles and Cuspation of the Incisai Edge

There is greater variation in the anatomy of

maxillary teeth than in those in the mandible,
as is shown by the larger variations in the
incisai embrasures of the maxillary dentition Fig 36 Intraoral view of maxilia and mandible
in a young person. Note iarge variations in the
(Fig 36). The reasons for these greater varia- incisai anatomy and embrasures in oí the maxil-
tions include the wider differences in the lary dentition as compared with that of the
thickness of the teeth and the developmental mandible.
angles formed by the mesial, central, and dis-
tal ridges of the labial and lingual surfaces.
The greater the difference in the develop-
mental angle when viewed in cross section

nm
Figs 37a to 37j Labial, linguai, mesial, distal, and incisai views of natural mandibular central incisor {a,b,c,d,e) ar
natural maxillary canine {f,g,h,i,j). Note the small differences in the developmental angles in the mandibular central in-
cisor when the mesial, central, and distal ridges of the labial and lingual surfaces are viewed from the proximal direc-
tion. In contrast, there are large differences in the developmental angles of the maxillary canine, These differences
affect the irtercuspation of the teeth.

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Fig 38 Illustration of process by which an in-

crease in developmental angles causes cusp for-
mation to become more pronounced. Note
how, as the angle between the compass legs
grows, the top of the compass is lowered.

mesially, centrally, and distally, the stronger Ten Check Points for Integrating the
the cusp formation. This is true in both maxil- Anatomic Variations of the Anterior
lary and mandibular teeth. The smallest dif- Teeth
ferences in the developmental angles are
found in the mandibular central incisors, so
The pattern of anatomic changes in the ante-
that the incisal edges of these teeth appear to rior teeth, gradually changing from the central
be in a straight line. The extent of cusp forma- incisor to the lateral incisor to the canine,
tion increases in the lateral incisor and canine, should be apparent. An understanding of this
and the teeth gradually take on an arrow-head pattern allows one to carry out anatomic mod-
shape. The differences in developmental an- ifications on particular points on the central
gles are much larger in the maxillary canines, incisor so that it will blend in with the other
where cusp formation is stronger (Fig 37). anterior teeth. This tooth is the key to a har-
To illustrate this principle, consider the com- monious restoration.
pass shown in Fig 38. As the angle formed by There are, in fact, 10 such check points, six
opening both compass legs equally increases, on the labial surfaces and four on the lingual
the height of the compass decreases. Likewise, surfaces (Figs 40a to 40f). Points 1 through 4
the cusp formation in the anterior teeth de- and 7 through 10 in Figs 40a to 40f mark
pends on the size of the developmental angle where carving of the cuspation of the incisal
(Figs 39a to 39c). The developmental angles edge occurs when teeth are viewed labialiy.
are smallest in the central incisor, which also Points 1 through 4 show the anatomic varia-
has the least conspicuous cusp formation. The tions of the incisal edge outline viewed from
lateral incisor and canine, with larger develop- the cervical direction, while points 5 and 6 il-
mental angles, have increasingly noticeable lustrate the constriction and torsion visible in
cusp formation. The outline of the incisal edge the cervical outline when viewed incisally.
of the teeth also changes with the variation in
the developmental angles.
Differences in the formation of the mesial,
central, and distal surfaces of the tooth be-
come more pronounced in teeth further away Essentials of Carving
from the midline. As a result, the pattern of
movement for the abrasives used during actual Points 1 through 4 mark the positions of the
anatomic modifications is such that it does not V-shaped grooves on the labial surface of the
impart much difference in the central incisor. tooth, and points 5 and 6 correspond to the
When working with the lateral incisor and ca- mesial and distal concave lines (Fig 40a). On
nine, it is therefore better to impart this differ- the central incisor, points 1 through 4 should
ence in the preparation of the three surfaces. be carved to follow the prescribed form. For

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

A B C A

Figs 39a lo 39c Diagrams of maxillary central incisor (top), lateral incisor (middle), and canine (bottom). Di-
agrams on left show the locations of the vertical sections through the lahial surface of each tooth: A = mesial
region; B = central region; C = distal region. Also shown are the cross sections of each of these regions
viewed from the proximal direction. Diagrams on right show the relationship of the cusp formation of the
tooth and the developmental angle of the ridge in the labiolingual section. The triangle formed hy the in-
clined surfaces shows the inclination of the ridges on the labial and lingual suifaces. The horizontal line con-
nects the highest points (central mamelon or cusp) of the incisal edge of each tooth. The greater the space
between this line and the peak of the triangle in the mesial and distal regions, the greater the cusp forma-
tion. Note also the distance between the upper line and the triangle (developmental angle) formed by the re-
spective labial and lingual surface ridges of each tooth. For the central incisor there is virtually no difference
between the developmental angles in the central, mesial, and distal regions, and the space between this line
and the peak of the triangle is small. However, in the lateral incisor and canine the difference in the develop-
mental angles becomes larger, and the space between the upper line and the triangle peaks also becomes
greater. As the difference in the developmental angles increases, there is a stronger tendency for cuspation.

the lateral incisor and canine, these points ing around in the proximal direction. Points 1
should be carved so that they fan out mesially through 4 should be carved deeper in the an-
and distally, so that they greatly lower the terior teeth farther from the midline.
incisal edge mesially and lingually while curv- In addition, the terminal position of points 3

84 QDT 1994
 CERAMiC RESTORATIONS

igs 40a to 40f The 10 carving points; there are six checkpoints on the labial surface and four on the lingual surface.

-ig 40a Direct view of the labial surface. Fig 40b Direct view of the lingual surface.

Fig 40c View of the mesial proximal surface. Fig 40d View of the distal proximal surface.

le View of the incisai edge. Fig 40f View from the cervical direction.

and 4, and 1 and 2 cervically, should be mony is preserved in variations of the labial
carved more sharply. Points 1 and 4 should be outline of each tooth, and a smooth anatomic
carved to define the line of the labial triangle transition is created in the associated teeth.
area toward the incisai edge. This allows for a The vertical separation between points 5 and
smooth transition, from the mesial to the dis- 6 becomes more pronounced and the area
tal sections, in the lahial surface ridges of the around point 6 becomes more clearly defined
central incisor, lateral incisor, and canine. Har- in the teeth further away from the midline.

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

The degree of constriction in the cervical re- incisor and canines, these points connect with
gion and the torsion on the mesial and distal point 6, the mesial region appears to bulge
regions are expressed by incorporating points out, and the distal region become constricted.
5 and 6. To express asymmetry and torsion in This expresses the asymmetry of the mesial
crown anatomy, more emphasis is placed on and distal halves of these teeth.
carving points 3 through 5 in teeth further Figure 40f shows points 1, 2, 3, and 4 from
from the midline. the cervical direction. In the teeth further from
Points 7 through 10 show the position of the the midline, points 1 and 4 should be carved
V-shaped grooves on the lingual surfaces of more boldly to curve in sharply in the proxi-
the teeth (Fig 40b), They are all about the mal direction. After reaching the incisai edge,
same level incisally on the central incisor. In points 2 and 3 are carved so that the central
the teeth further from the midline these points ridge projects outward, and the V-shaped
are carved more strongly and cut to curve groove seems to appear on the incisai edge. As
more significantly proximally. This creates a mentioned earlier, the V-shaped grooves can
greater slope cervically in the lateral incisor be made to appear toward the incisai edge by
and canine. In addition, the difference in the carving points 1 through 4 deeper in the lat-
developmental angles, which are formed by eral incisor and canine.
the mesial, central, and distal labial surface
ridges defined by points 1, 2, 3, 4 and 7, 8, 9,
10, becomes larger in these same teeth. Con-
currently, cuspation arises in the incisai anat- The Actual Carving
omy and a slight unevenness appears in the
incisai edge. As an example of the effect these points have
In the lateral incisor and canine, points 1, 7, on teeth, they were carved into three identical
4, and 10, in this order, are carved deeper in casts which were formed by flowing resin intu
the labiolingual direction (Figs 40c and 40d). an impression of a central incisor (Figs 41a to
When this is done, the difference in the devel- 43e).
opmental angle as defined by the central la- In Figs 41a to 41c, the widthidepth ratio
bial and lingual ridges becomes greater, and of the teeth on the right side changes to pro-
the distance between the intersection of points duce a good balance in the anatomic varia-
1 and 7 and 4 and 10 with the central tubercle tions of the teeth adjacent to the central
becomes greater. A line separating points 1 incisor; the transitional surfaces have also
and 7, 2 and 8, 3 and 9, and 4 and 10 crosses been correctly incorporated. Comparing these
the tooth in the incisai region (Fig 40e). teeth with those on the left side, it is apparent
Points 5 and 6 are carved primarily to ex- that anatomic variations have been achieved
press the constriction in the cervical region, here by solely carving the 10 points similarly
the torsion of the tooth, and asymmetry be- in each central incisor, without taking into ac-
tween the mesial and distal halves of the count the anatomic variations in the adjacent
tooth. The carving of point 5 is carried out pri- teeth. The teeth have a certain amount of har-
marily on the transitional surfaces, proximally, mony, but they are flat and lacking in fullness.
so as not to section the labial surface ridges. In An impression was taken of a central incisor,
contrast, point 6 is carved bolder in teeth fur- three resin models were made (Fig 42a), and
ther from the midline. This is done not only the 10 points mentioned here were carved
on the transitional surfaces, but also on por- (Figs 42b to 42g). Note that because only one
tions of the labial surface proper. Carving in type of central incisor was used as the basis
these areas naturally constricts the proximal for fabricating the examples in Figs 42a to
outline and expresses torsion in the tooth. In 42g, the width:depth ratio needed to incorpo-
addition, the characteristic double curve is ex- rate the anatomic variations of the associated
pressed in the distal region. By carving points teeth has not been realized. In particular, the
3 and 4 in the cervical direction in the lateral fullness of the cervical and the central regions

86 QDT 1994
 CERAMIC RESTORATIONS

Figs 41a lo 41c Example of how anatomic variations established by incorporating the proper width depth ra-
StioTof'aSerior Ï e t ï " ' " ° " ' ^""' ' " ' ^"^"'^ "^"^' checkpoints'comhi^ to ^rea'te harmontoïs r«-

Fig 41a Frontal view of six anterior teeth carved

to compare restorations fabricated using only the
10 carving points {left) with those fabricated while
aiso taking into consideration the anatomic varia-
tions and the widthidepth ratio of the associ-
ated teeth (right). The six anterior teeth shown all
have the same mesiodistal dimension. Compare
the labial surfaces of the three teeth on the ieft,
which lack fullness because their width;depth ra-
tios are all the same, with those on the right,
which have the proper ratios.

Fig 41b Lateral view of a lateral incisor and Fig 41c Lateral view of crowns (the teeth on
canine (the teeth on the left m Fig 41a} that the right in Fig 41a) with porcelain extending
were fabricated and arranged from identical to the root that were fabricated and arranged
central incisors. Anatomic variations were based en the left centrai incisor as the key
made according to the 10 carving points. tooth. Anatomic variations were carried out on
the associated teeth while incorporating the
proper width:depth ratio.

uf the crown appears deficient both labially Expression of the Labial Triangular Area
and lingually in the teeth farther from the
midline. This shows the importance of incor- When fabricating anterior restorations, avoid-
porating such variations during the actual clin- ing too strong an appearance in any individual
ical modifications by properly carving the 10 tooth is important. It is also essential that the
check points after first considering the arrangement of the teeth is as near as possible
widthidepth ratio of the teeth. Furthermore, to normal, so close attention must be paid to
depending on the patient, there may well be the labial triangular area when fabricating the
restrictions on the width:deptb ratio. crowns. If, for example, only a lateral incisor is
The teeth were arranged in Figs 43a to 43e missing and other anterior teeth are in their
so that they can be seen as a set. The figures normal positions, the form of the restoration
and their legends explain the actual carving of may be harmonized by keeping the labial tri-
the 10 checkpoints. angle in mind during fabrication.

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Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Fig 42a to 42g Central incisor, lateral incisor,

and canine fabricated and arranged from resin
models of the same central indsor as In Fig 41.
Anatomic variations were added using the 10
carving points. Although the width:depth ratio
and mesiodistal dimension were the same for all
three of the teeth, it was possible to incorporate
considerable anatomic variation simply by carv-
ing the six labial and the four lingual points.

Fig 42a Resin models of the central incisors

fabricated from impressions of the same tooth.

Fig 42b Direct view of the labial surface. Fig 42c Direct view of the lingual surface. A
Cusp formation of the incisal edge is expressed decline in the height where the marginal
by carving points 1, 2, 3, 4, 7, 8, 9, 10 in the ridge begins is achieved by carving points 7
incisal region. A constricted, twisted appear- and 10, and the accessory ridges at the incisal
ance is expressed in the cervical region by carv- region are brought out by carving points 7, 8,

rmrm
ing points 5 and 6. 9, and 10.

Fig 42d and 42e Views of the mesial and distal surfaces. The slope where the labial and lingual sur-
face ridges cross the incisal edge on the mesial, central, and distal regions is expressed by the extent
to which points 1 and 7 and 4 and 10 are carved.

Fig 42f Incisal view. The cervical region be- Fig 42g Cervical view. Points 1 and 4 affect the
comes more constricted in the teeth further projection of the central region. Also, the
from the midline depending on the extent to V-shaped grooves are brought out in the vicinity
which points 5 and 6 are carved, resulting in a of the indsal edge by carving points 1,2,3, and 4.
protruding appearance. Also, the constriction of The asymmetry of the mesial and distal V-
the tooth and the asymmetry of the mesial and shaped grooves in tho teeth farther from the mid-
distal halves can be expressed by the extent io line can be expressed by lengthening the connec-
which points 1,2,5 and 3,4,6 are carved. tions between points 3 and 6 and 4 and 6.

88 QDT 1994
 CERAMIC RESTORATIONS

mrm
Figs 43a 10 43d The same teeth as in Figs 42a to 42g after modifications

Fig 43a Labial surface view. The smooth tran-

sitions in the inclined surfaces of the mesial Fig 43b Lmgual surface view. The transition
and dista) areas near the incisal edges of the of the marginal ridge for the teelh that are far-
lateral incisor and canine are prepared by carv- ther from the midhne is expressed by establish-
ing points 1 and 2 and 3 and 4. The gap in the ing points 7 and 10 on the lingual triangle line.
mesial line angle region is created by carving
point 7. The labial triangular area is'properly
balanced by establishing points 1, 4, and 6 on
the labial triangle line.

Fig 43c Incisal view. Note that all of the teeth Fig 43d Cervical view. The incisal embrasures
look the same because the transitional surface are expressed by carving points 1, 2, 3, and 4.
towards the proximal region is not carved. Con- The orientation of the prescribed form of the
sequently, there is no difference in the labial mesial and distal ridses is also established.
embrasure, which would result from the natu-
ral anatomic variation in the original associated
teeth. It is necessary to incorporate the labial
embrasures separately from the 10 carving
points when making the anatomic
modifications.

The Three Basic Tooth Forms and the round, and tapered) have different effects on
Labial Triangular Area the labial triangle area.
The upper and lower triangle lines are al-
The labial triangular area is not always the most parallel in the square tooth, in which the
same shape in each tooth, and also differs ac- area of the triangle region is also the greatest
cording to the specific characteristics such as (Fig 44a). In the round tooth, the upper and
tooth alignment, facial features, and sex of the lower lines are essentially parallel, but, com-
patient The three basic tooth shapes (square. pared to the square tooth, they are more cen-

QDT 1994 89
Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

A, square A, young

B, round B, middle-aged

C, tapered C, elderly

Figs 44a to 44c Drawings of the three basic crown Figs 45a to 45c Examples of labial surface and triangle
shapes of the surface of the anterior teeth showing the areas in the young, middle-aged, and elderly.
labial triangle area (upper line = incisai edge, lower line
= labial triangle area).

trally located. The area of the region is also strong tendency to rise up in teeth away from
smalier (Fig 44b). Although the incisai line of the midline. For this reason the triangular area
the tapered tooth is nearer the incisai edge of this type has the strongest tendency to con-
than in the square or round teeth, it has a strict in these teeth (Fig 44c). In addition, it is

90 QDT 1994
 CERAMIC RESTORATIONS

Fig 46 Illustration of use of disk to create the anatomy of the connecting region. Note that the tooth
contact point become shorter vertically in the associated teeth farther from the midline, and its position
also moves towards the center of the crown.

necessary to keep in mind that the shape of shorter vertically in the lateral incisor and
the labial triangular area also differs in long or canine.
short teeth independently of their shape.

Variations in the Triangular Area With Actual Restoration of Anterior

Crowns
Even in the same dentition, the triangular area Three clinical cases and a model case were
changes with age. Although the anatomic fea- used to illustrate actual restorations of crowns.
tures of a younger person's dentition is not In all clinical cases (Figs 47a to 47f), the pa-
much changed from that which existed when tients' oral cavities were first observed to sug-
their teeth first erupted, attrition of the incisai gest an ideal basic anatomy for the restora-
edge is pronounced in middle-aged and eld- tions based on the condition of adjacent teeth,
edy persons. Attrition normally starts in the and attempts were made to harmonize the
canine and progresses to the central and lat- dentition. Prostheses were prepared following
eral incisors. Furthermore, recession of the the rules guiding basic tooth anatomy for cre-
periodontal tissues increases with age. For this ating a balanced dentition and for varying the
reason, the labial triangular area appears to anatomy of anterior teeth as outlined earlier.
move incisally with age (Figs 45a to 45c),

Clinical Case 1
The Importance of the Contact Area of
the Connector Porcelain-fused-to-metal crowns were fabri-
cated for both maxillary central incisors and
The connecting region, corresponding to the the maxillary left lateral incisor of this patient.
contact areas of independent teeth, is often Almost no attrition of the incisa! regions or
overlooked when doing anatomic modifica- abrasion of the labial surface were present.
tions on a restoration. It is necessary to The basic tooth shape was flat and rounded,
shorten this area vertically in teeth farther with a certain amount of rotation. Inspection
from the midline and manipulate the polish- of the oral cavity revealed crowns that had
ing material of the disc, which determines the been fabricated on standard forms, giving the
anatomy of the connecting region (Figs 46a appearance of teeth that had just erupted.
and 46b), so that the contact has a long verti- The left lateral incisor was matched to the
cal shape at the central incisors and becomes anatomy of the root cross section at its mar-

QDT 1994 91
Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Figs 47a to 47f Three clinical cases in which all of the patients' oral cavities were observed, images
were established for the basic anatomy of the teeth to be restored based on the condition of tbe adjacent
teeth, and attempts were made to establish harmony in the dentitions. The prostheses were prepared as
per the principles discussed earlier and before treatment photographs (a,c,e) and posttreatment photo-
graphs (b,d,fl are shown.

gin, the adjacent canine, and the contralateral incisor of this patient, who desired a restora-
incisor. The central incisors were fabricated by tion in harmony with existing teeth.
inferring their anatomy from the lateral inci- Special anatomic characteristics included at-
sors and canines. trition of the incisai edge and a certain amount
of abrasion on the labial and lingual surfaces,
as is typical in a middle-aged person. The res-
Clinical Case 2 toration was harmonized with the adjacent
teeth and incorporated the anatomic variations
A prosthesis was fabricated for both maxillary of the adjacent teeth while expressing these
central incisors and the maxillary left lateral special characteristics.

92 QDT 1994
 CERAMIC RESTORATIONS

Figs 48a to 48h Samples of anterior teeth formed by fabricating a central indsor based on the basic an-
atoniic type and the age of tbe patient. Note changes in crowns representing those for older patients. La-
bial surface abrasion becomes more pronounced and marked attrition appears in the incisal edge.

Fig 48a Square-shaped tooth of a younger Fig 48b Round-shaped tooth of a younger
patient. patient.

Fig 48c Tapered tooth of a younger patient. Fig 48d Ovoid tooth of a younger patient.

Fig 48e Mixed tooth of a younger patient. Fig 48f Teeth of middle-aged pahent.

Fig 48g and 48h Teeth of elderly patients.

QDT 1994 93
 Nishimura • Reconstruction of coronal anatomy in ceramic restorations of the anterior teeth

Clinical Case 3 toration of anterior crowns has moved forward

in such aspects as coloration and construction
A prosthesis was fabricated for the right and of natural teeth, the technology of materials
left maxillary canines, right and left maxillary has also progressed. The point has now been
lateral incisors, and right and left maxillary reached where theoretically based technical
central incisors. The patient was a young expression can be carried out. On the other
woman who expressed a desire for young hand, even though a person might learn the
looking, bright, feminine teeth. fundamentals of dental anatomy, the anatomic
The teeth were of the round type and had a expression of the final product may be want-
youthful appearance. The round shape was ing if one does not understand how to carry
preserved in the maxillary central incisors, out the technique. In the past, the technician's
which were used as a basis for establishing the instincts took precedence over theoretic con-
anatomic variations in the maxillary lateral in- siderations. For this reason, it took beginners a
cisors and canines. very long time and considerable experience to
master anatomy.
The development of a basic theory and crite-
Model Restoration ria for the fabrication of a restoration hastens
this process. The ability to fabricate clinically
The central incisor was fabricated based on a acceptable restorations of all anatomic types
standard anatomic type as described earlier may then be acquired easily and in a mini-
This tooth was then used as the basis for a mum amount of time by anyone who has a
model of the anterior dentition that would certain degree of practice and has learned
preserve the anatomic variations of the associ- these theoretic foundations.
ated teeth. Fabricating a restoration that is in harmony
Figures 48a to 48e show model dentitions with the remaining dentition and that ex-
for a young person. Fig 48f shows a model presses the coronal anatomy of anterior teeth
dentition for a middle-aged person, and Figs requires an understanding of both the anat-
48g and 48h show model dentitions for an omy of the teeth and the means necessary for
older person. achieving this harmony with the adjacent
Note that the anatomy of each tooth teeth. This article was structured to simplify
changes with age. Marked attrition appears in the guiding principles needed to accomplish
the incisal edges of the teeth, and a strong, such restorations and set them forth from a
carved-out abrasion appears on the labial sur- dental technician's viewpoint.
faces. Attrition in the incisal regions cause the
labial triangle areas and embrasures of the
incisal line angles to appear different in the A cknowledgm en Is
teeth of older persons. As abrasion from The author would like to express gratitude to his em-
toothbrushes and the lips lead to acquired an- ployer, Dr Ryuji Fujii, head of the Fujii Dental Clinic, for
atomic changes on the labial surfaces, it is contributing his time and assistance in preparation of
necessary to consider such variation when this manuscript and his cimical examples; to Drs Shigeo
fabricating crowns for older patients. Kataoka, Mitsuru Morihiro, and Hiroto Yamamoto for
their advice and checking of the manuscript; to Mr Yuji
Okubo, who was in charge of the illustrations for the
manuscript; and to the staff at the Misshin Company
Conclusion who provided material for the skull photographs.

As the statistical and scientific elucidation of

the expression of the shade and anatomic res-

94 QDT 1994