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Classification of Altered Dental

Esthetics

Howard B. Kay, DDS* Dentistry has always been subject to

therapeutic trends that tend to
dominate the subject matter of pro-
fessional meetings and the dental
Clinical procedures designed to reestablish the idealized framework for the literature. During each of these
achievement of optimal esthetic restorative results have been frequently report- trends, the profession generally
ed. Yet complex cases, where remarkable improvements of esthetic appearance applies considerable focus on the
are achievable in spite of preoperative conditions, are infrequently presented subject, fostering enhancements,
because the presentation standards appear to be set for idealized situations. If a research, and broadened applica-
classification system that reflects dental esthetic compromises and ideals existed, tion of the prescribed methods as
cases could be categorized accordingly, and realistic expectations could be
well as expansion of the scope of
applied to assess the effectiveness and results of a course of therapy. Considering
associated modalities. Today, there
that there is not currently a published classification system to this end, it is the
has emerged a focus on esthetic
purpose of this article to tender a classification of altered dental esthetics.
dentistry centered on the ability of
(Int J Periodontics Restorative Dent 2002;22:85–94.)
the clinician and technician to recre-
ate the appearance of the natural
dentition with extraordinary ele-
gance. Research, technology, and
innovation have fostered clinical
procedures that are intended to re-
establish the proper environment
for the recreation of optimal restora-
tive esthetics. There has been a
focus on the surgical disciplines and
orthodontics for both general as
*Visiting Adjunct Associate Professor, Department of Graduate well as implant prosthodontics. This
Prosthodontics, College of Dental Medicine, Nova Southeastern no doubt has been an important
University, Ft Lauderdale; and Private Practice Limited to Prosthetic phase in the achievement of quality
Dentistry, West Palm Beach, Florida.
dental esthetics. There are demon-
*Reprint requests: Dr Howard B. Kay, 2521 North Flagler Drive, West strated capabilities and high stan-
Palm Beach, Florida 33407. dards for quality dental esthetics, if

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the idealized esthetic environment is (females generally show twice as should be parallel to the commis-
reestablished. much of the maxillary incisors as sure plane. The “smile line” should
Such an idealized esthetic envi- males). be convex and follow the curvature
ronment is one where the patient’s The vertical references are the of the lower lip. Unworn incisal
dentoalveolar complex is intact and facial midline, axis of the dental mid- edges and pronounced incisal
demonstrates characteristics that are line, and mediolateral assessments embrasures are associated with
in harmony with the “framework” of of tooth position. Ideally, the facial youth and femininity, whereas worn
the esthetic dental composition.1 midline and axis of the dental mid- incisal edges and diminished incisal
The components of the framework line should be parallel and coincide, embrasures are associated with
include, but are not limited to, the but minor deviations are not neces- aging and masculinity.2,4–6
following. sarily distracting.1,2 Gingival composition describes
The horizontal references are The sagittal references include the esthetic makeup of the gingival
lines that ideally are parallel to the the nasolabial angle (in males 90 to tissues that “frame” the teeth.
horizontal plane. Primarily, they are 95 degrees and in females 100 to Gingival levels on central incisors
the interpupillary line, incisal plane, 105 degrees), which allows assess- should be the same, while lateral
gingival margins, and maxillary ment of upper lip support derived incisors can display subtle deviations.
occlusal plane. There are also acces- from the gingival two thirds of the The “gingival aesthetic line” (GAL)
sory lines that include the ophriac, maxillary anterior teeth. The Rickett’s described by Ahmad2 is the line con-
commissural, and interalar lines. E plane is used to evaluate the pro- necting the zeniths of the central
Other horizontal references include file and maxillomandibular relation- incisors and canines and intersects
the lip lines that are assessed in both ships. The Camper’s plane should the dental midline. The GAL can be
static and dynamic states. The upper parallel the occlusal plane.1,2 esthetic in several patterns as long as
lip at rest allows for evaluation of the The phonetic references include there is a sense of order. Angles can
maxillary incisal position and in a the “M” sound, used to determine be 45 to 90 degrees, with the lateral
dynamic or smile state allows for rest position (with absence of tooth incisors on or 1 to 2 mm above/
assessment of the position of gingi- contact) and assessment of the dis- below the GAL. Gingival contours, in
val tissues. The lower lip phoneti- play of the maxillary incisors at rest. health, tend to follow the form of
cally determines the labiolingual The “F” or “V” sounds help deter- the underlying bone. When there is
position of the maxillary incisors and mine the lingual tilt of maxillary a scalloped form, there is generally
in a dynamic state provides a guide- incisal edges, and the “S” position is closer root proximity. When shallow
line for the curvature of the incisal used to capture the vertical dimen- form is displayed, the roots are usu-
plane.1,2 sion of speech with near maxillo- ally divergent or a diastema may be
The “LARS factors,” as des- mandibular incisal edge contact.1,3 present. Gingival zeniths of the cen-
cribed by Ahmad,2 provide infor- Dental composition also in- tral incisors and canines are distal to
mation for determining the appro- cludes the evaluation of the size, the long axes of these teeth, and the
priate display of the maxillary shape, and intra- and interarch rela- zeniths for lateral incisors are closer
anterior teeth. These factors are: lip tionships of the teeth. The central to the long axis. The interdental
length (static: short, medium, long); incisors should have a 7.5:8.0 width- papillae should be intact, and gingi-
age (the elderly typically show less of to-length ratio and be dominant to val exposure during smiling should
the maxillary and more of the man- be most esthetic. The “golden pro- be 3 mm or less to generally be con-
dibular anterior teeth); race (patients portion” is an ideal, but it is not sidered esthetic.1,2
of African descent frequently display always evident. The axial inclinations Symmetry and diversity also play
less of the maxillary anterior teeth of the anterior teeth should con- roles in the evaluation of the esthetic
than Caucasian patients); and sex verge medially, and the incisal plane composition. Currently, many

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patients are influenced by the However, if such esthetic com- 5. It facilitates the projection of the
“media smile,” which has an altered promises were included in a classifi- limitations of treatment and the
ideal compared to the more natural cation, cases could be categorized final result of therapy that is likely
esthetics of teeth. To many, even accordingly, and levels of realistic achievable.
incisal edges and white teeth now expectations could be applied to
equate with youth and success, and assess the effectiveness of therapy. In general, a classification sys-
dentistry frequently has to overcome The literature presents several dif- tem facilitates the recognition of
this stereotypical image to effect a ferent classification systems that problems, communications between
truly beautiful smile. In design, sym- have bearing on esthetic results and cotherapists, planning of treatment,
metry or very subtle asymmetry ample references to various guide- and expression of achievable results
should exist close to the midline, lines for assessing dental esthetic to the patient. In any aspect of treat-
whereas greater asymmetries are composition. There are also descrip- ment, this is invaluable.
acceptable away from the midline. tions of the conditions that can
Also, the dental midline may deviate detract from optimum appearance;
from the facial midline in many situ- however, a classification that includes
ations and still be esthetically pleas- esthetically compromised case types
ing.1 has not been presented.7–15 Consid-
The expansion of the current ering that there is not currently a
state of esthetic dentistry should published classification system to
include identification of the charac- this effect, it is the purpose of this
teristics associated with cases with article to tender such a classification
more advanced esthetic compro- of altered dental esthetics.
mises and determine which clinical Prior to presenting a classifica-
corrections need to be applied in tion of altered dental esthetics, it
each situation to create the most would be helpful to delineate some
optimum environment, or frame- of the reasons such a system would
work, for esthetic restoration. It is be beneficial to the clinician:
evident that not all situations lend
themselves to an optimum result, as 1. It facilitates visualization and
noted above. The well-managed communication of the problems
case with advanced problems, where associated with the case type.
remarkable improvements in esthetic 2. It connotes the degree of diffi-
appearance are achieved, can be as culty of accomplishing the re-
elegant as an “optimum” case when quired correction of the associ-
the preoperative condition is con- ated problems.
sidered. However, these types of 3. It establishes a basis for project-
cases are not often presented in ing the time needed to achieve
esthetic dentistry forums because the necessary treatment objec-
the standards for presentation tives.
appear set to the idealized situation. 4. It establishes a framework and
This limits the value of presented some general guidelines for pro-
cases and techniques because of the jecting fees commensurate with
narrowed scope and redundancy the level of difficulty of treating
that has become so evident. the patient.

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The classifications clinical abilities of the operator and precede completion of restorative
the technical quality of the labora- endeavors.18–27 Once the esthetic
Altered dental esthetics are divided tory support. The focus is primarily framework is reestablished, the Class
into four classes. In each class, the on the choice of the optimal restora- I restorative objectives would then
condition of the framework of tion. Proper soft tissue management be applicable (Fig 2).
esthetics represents the basis for the during therapy is essential. Impres-
classification. In a sense, the restora- sion making must be minimally trau-
tion becomes the object of art on the matic, and the provisional restora- Class III: Significant alterations
canvas, and the condition of the sup- tions must be of a quality that in esthetic framework
porting structures becomes the enhances tissue health. Proper tooth
frame that enhances the presenta- preparation is critical to enable the In the Class III situation, the esthetic
tion. The influential framework con- laboratory technician to achieve a framework presents with one or
sists of: quality result. Here, excellent labo- more advanced alterations. There
ratory results will enhance clinical may be occlusal plane deviations,
1. Integrity of the dental arches, management, but they cannot com- severe midline shifts, or other ortho-
including missing teeth, general pensate for poor clinical controls16,17 dontic problems that present with
condition of the teeth, occlusion (Fig 1). Of special note, in Class I limited prognoses because of insuf-
problems, occlusal plane alter- cases as well as the more advanced ficient or poor anchorage, deficiency
ations, midline discrepancies, situations, a high lip line will always of alveolar bone dimension, or pa-
and tooth position alterations create a higher degree of treatment tient noncompliance. Osseous de-
2. Integrity of the osseous support, difficulty. fects requiring potential grafting pro-
including the level of the osseous cedures may not be as predictable
crest, ridge deformities, tooth because they may require vertical
mobility, periodontal defects, Class II: Minor alteration in augmentation as opposed to more
and clinical crown lengths esthetic framework predictable horizontal augmentation
3. Integrity of the gingival tissues, procedures. Patients may tire of re-
including soft tissue levels, In the Class II situation, there are peated surgeries and refuse addi-
mucogingival deficiencies, gin- minor alterations evident in the tional procedures before all of the ini-
gival clefts, and gingival asym- esthetic framework. The patient may tial objectives are achieved. Clinically
metries present with a minor midline dis- elongated teeth with loss of inter-
4. Orthognathic alterations crepancy, minor gingival height dis- dental papillae may create esthetic
crepancy, a hopeless or missing compromises that are not amenable
tooth but intact osseous and gingi- to total elimination. There may be
Class I: Intact esthetic val tissues, minor noncomplicated significant loss of periodontal tissues
framework orthodontic problems, or perhaps a or marked edentulous ridge loss or
noncomplicated implant situation. deformation, or the patient may have
In the Class I type, the esthetic In each of these situations, the prob- hopeless or missing teeth with sig-
framework is intact. The skeletal, lems are readily correctable with nificant loss of osseous substructure.
osseous, and gingival architecture appropriate treatment, and the case Unlike Class II cases, in these cases
and the dental arches require no is readily convertible to Class I status. the esthetic framework may not be
alteration. The only esthetic require- In these circumstances, appropriate converted readily or predictably to
ment is the restoration of the teeth. and predictably achievable ortho- Class I status. Yet, with appropriate
Here, the achievement of the treat- dontic, periodontic, endodontic, treatment, a reasonably acceptable
ment objective is limited by the and oral surgical procedures must appearance should be achievable as

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Fig 1a Patient expressed concern over the incisal wear of the Fig 1b Restoration of both maxillary central incisors and the right
maxillary central and right lateral incisors. She wished to have lateral incisor was accomplished using porcelain laminate veneers
esthetic correction accomplished but was concerned about main- fabricated to be in harmony with the appearance of the adjacent
taining a natural appearance. The esthetic framework was intact, teeth. Here, as in other Class I examples, no procedures were
exemplifying a Class I situation. required prior to the restorations.

Fig 2a This patient disliked the appearance of the existing cer- Fig 2b Original fixed partial denture was made with the left central
amometal fixed partial denture on the maxillary right central incisor incisor as a modified ridge-lap pontic. In the new restoration, this is
to the left lateral incisor. She objected to the appearance of the contoured as an ovate-type “emergence” pontic. The patient had an
“dark line” around the gingival collar of the right central incisor and abundant amount of keratinized attached gingiva over the edentu-
to the open papillary space between the central incisors. She also lous ridge, suggesting that a gingival graft had previously been per-
expressed a desire for a general overall enhancement of her smile, formed, although the patient could not recall. In the process of the
emphasizing that she wished to have brighter and more even teeth. gingivoplasty to establish the ovate pontic, the proximity of the labi-
al frenum became apparent. A frenectomy was performed to stabi-
lize the tissues. The patient wished to have the restorations extend-
ed distally into the premolar areas to enhance the esthetic result. All-
ceramic single units were used, with the exception of the fixed
ceramic segment between the right central and left lateral incisors.
Attention was given to the establishment of a more youthful smile
line as well as correction of the patient’s initial concerns. In this Class
II case, the esthetic framework was essentially intact and only minor
soft tissue corrections were required prior to restoration.

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Fig 3a This patient presented with signifi- Fig 3b Radiographs demonstrate the
cantly more advanced problems. The max- severity of the problem. The fragile inter-
illary left central and lateral incisors were septal bone between the two hopeless
hopeless because of advanced bone loss teeth would likely be lost following extrac-
associated with failure of prior endodontic tion, resulting in a depression in the ridge
procedures and apicoectomies. The loss of and loss of the papillae needed for main-
these teeth would result in a very signifi- tenance of an esthetic appearance. This
cant defect in the patient’s anterior maxilla. case would be classified as Class III
because of the advanced nature of the
problems and unpredictable nature of
total preprosthetic repair.

long as the clinician and the patient plane alterations (Fig 4).35–37 If the
understand that some compromise patient presents with solely Class IV
from the ideal is necessary.27–34 It is problems, these cases can be con-
best that this understanding is verted to Class I with appropriate
reached at the onset of therapy orthognathic and orthodontic pro-
rather than at the end, when the cedures. It must be recognized that
patient could be disillusioned be- some patients will resist orthognathic
cause of unrealistic expectations. In surgery; in this case, nontreatment
these cases, recognizing the ap- will mean compromise of the poten-
propriate class type preoperatively tial idealized result. On the other
will be of benefit in realizing poten- hand, some patients become very
tial limitations and translating these enthusiastic when they learn of pos-
to the patient (Fig 3). sibilities and options that are avail-
able to them. If Class II problems are
also present, these must be treated
Class IV: Orthognathic in the same manner as if the orthog-
deformities nathic component were not present
(Fig 4b). Problems can be worsened
An orthognathic problem by itself if Class III esthetic framework com-
constitutes a compromise in the promises are superimposed. In some
esthetic framework, even if all other cases, the severity of the Class III
framework aspects are intact. These problems can be lessened if these
include severe angle Class II or III are addressed in conjunction with
deformities, anterior open bite, ver- the orthognathic treatment. In many
tical maxillary excess, marked asym- advanced combination cases,
metry, and severe occlusal or incisal patients sometimes will happily

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accept an improved appearance that

is not ideal, because orthognathic
therapy tends to be dramatic. This is
especially true if the patient appre-
ciates the scope of their problems
and is given an understanding of the
limitations associated with the cor-
rection of the various aspects of their
esthetic condition.
Figs 3c and 3d Following the extractions, ridge reconstruction was accomplished by
Generally, when treating pa- means of guided bone regeneration, followed by a subepithelial connective graft to add
tients with esthetic problems, the facial and ridge height. This was done simultaneously with a contiguous free gingival graft
on the ridge crest that obturated the space in the crestal incision. These procedures
clinician should attempt to reduce reestablished the labiolingual contours as well as the height of the edentulous ridge and
the patient’s circumstances to the created a situation where ovate pontics could be employed. (Periodontal surgery per-
formed by Dr Robert L. Holt, West Palm Beach, Fla.)
lowest achievable class status. Re-
sults are also limited by the patient’s
acceptance of therapy, compliance,
and healing response.

Using the classifications

Patients can be described using a

preoperative class in combination
with achievable or achieved post-
operative classification. Figs 3e and 3f Ovate pontic form development in conjunction with prosthetic increase in the
incisogingival length of the contact areas enabled the partial reestablishment of the interdental
papillae. The creation of greater dominance of the central incisors draws the eye away from the
tissues and presents an overall very acceptable and pleasing esthetic appearance for this
Preoperative classifications attractive 36-year-old woman. Her lip line also provides ample coverage for her gingival tis-
sues. The postoperative radiographs demonstrate the reconstruction of the osseous deformity.

If the patient’s condition can be

effectively described by one classi-
fication, then it would be simply
stated as Class I, II, III, or IV. If a
patient has combined characteris-
tics, the condition would be classification of the overlying as Class II-I, using a hyphen (-) to
described using a virgule (/) to sep- esthetic framework problems (eg, symbolize the change. The same
arate the classes (eg, Class II/III). Class IV/III or Class IV/II). would apply to other classes that are
This might be used to describe a returned to Class I status (eg, Class
patient with generalized Class II III-I or Class IV-I). If the patient has
characteristics but some localized Postoperative classifications combined characteristics (eg, Class
Class III areas. If the patient has an IV/III or Class IV/II) and is successfully
underlying orthognathic condition, A Class II patient who completes treated, the case could be described
however, this characteristic would treatment with successful conversion as Class IV/III-I or -II, indicating
be expressed first, followed by the to Class I status would be referred to restoration to a Class I or II status. If

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the patient were restored without

reduction of class because of lim-
ited results or nonacceptance or
compliance with treatment, the
description would express only one
class (eg, Class II-II).
If the patient is restored to an
acceptable esthetic appearance in
Figs 4a and 4b This 17-year-old female suffered development of a severe anterior defect
spite of residual underlying frame-
caused by a large resorptive lesion on the maxillary left central incisor root. The lesion was work deficiencies and prosthetic
the sequela of a long and poorly controlled orthodontic program designed to treat the con- methods were used to conceal these
genital absence of the lateral incisors by bringing the teeth posterior to the spaces forward
to contact the distal surfaces of the central incisors. Her esthetic condition was further com- residual problems, then the case
promised by the ectopic eruption of the right first premolar anterior to the right canine and could be described as having a “cos-
altered passive eruption on the right side.
metic” result. These measures would
include techniques such as use of
tissue-colored porcelains to simu-
late missing papillae or conceal
excessive crown length.34 Remov-
able gingival masks would also be
included in this description. The
term cosmetic would be used to
describe concealment, as opposed
to “esthetic correction,” which
would imply elimination of the prob-
lem through therapeutic measures.
Figs 4c and 4d Following extraction of the hopeless central incisors and initial healing, the Thus, when “(cosmetic)” is used at
patient refused to undergo any procedures recommended to reconstruct the edentulous
ridge. This eliminated the ability to reduce the excessive clinical crown length or place estheti- the end of a description, it would
cally positioned implants. The patient agreed only to have periodontal surgery to achieve indicate that all or some of the un-
pocket elimination and correct the altered passive eruption. This did help to improve the levels
of the gingival tissues. The apical positioning also helped to narrow the root dimensions of the
derlying problems are still present,
right first premolar and left canine, which were in the lateral incisor positions. This facilitated but they are concealed through
the contouring of these restorations as lateral incisors. The left first premolar was also shaped prosthetic techniques rather than
to resemble a canine. The patient was restored with a fixed ceramometal restoration using gin-
giva-colored ceramics to simulate the replacement of lost soft tissues and reduce the appear- having been successfully corrected
ance of excessive clinical crown length. In this situation, the patient’s Class III framework status through therapy. Therefore, the clas-
was not reduced and a prosthetic method was used to achieve a Class III-III (cosmetic) result.
sification would be stated as Class III-
III (cosmetic) if there were no cor-
rective measures achieved (Fig 5). If
partial esthetic framework correction
were accomplished prior to the ap-
plication of the prosthetic measures,
then the situation could be des-
cribed as Class III-II (cosmetic).

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Fig 5a This patient's Class IV “gummy smile” results from vertical Fig 5b Following the orthognathic surgery, the patient still has a
maxillary excess that can only be corrected by surgical means. minor problem with the level of the gingival tissues on the maxil-
Here, she is depicted undergoing orthodontics in preparation for lary right lateral incisor. Her appropriate esthetic classification
orthognathic surgery. would therefore be Class IV-II prior to any additional treatment and
Class IV-I if the altered gingival height were corrected.
(Photographs courtesy of Dr Stephen Rimer, Boca Raton, Fla.)

Conclusion Acknowledgment 4. Burger S. The arrangement of anterior

and posterior teeth in the natural denti-
I would like to express my sincere gratitude tion. In: Schärer P, Rinn LA, Kopp FR (eds).
The use of a classification of altered
to Dr Robert Holt for his editorial assistance Esthetic Guidelines for Restorative
dental esthetics would facilitate the Dentistry. Chicago: Quintessence,
in the preparation of this article.
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between cotherapists, planning of Pract Periodontics Aesthet Dent 1998;10:
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