Esthetics in CD Prosthodontics Dr.

Mohammed Hussein
M. Alsharbaty

Esthetics Considerations in Complete Denture

Esthetics: 1. The branch of philosophy dealing with beauty;
2. In dentistry, the theory and philosophy that deals with beauty and the beautiful,
especially with respect to the appearance of a dental restoration, as achieved
through its form and/or color; those subjective and objective elements and
principles underlying the beauty and attractiveness of an object, design, or
principle.
Dental esthetics: The application of the principles of esthetics to the natural or
artificial teeth and restorations.
Denture esthetics: The effect produced by a dental prosthesis that affects the
beauty, attractiveness, character, and dignity of an individual. It is a combination
of art and science of prosthodontics.
Factors Influencing the Appearance of Dentures:
• Patient factors
• Tooth factors
• Denture base factors
• Tooth/Denture base factors

• Patient Factors
• 1. Sex
• 2. Age
• 3. Personality

• Tooth Factors
1. Position
2. Color
3. Size
4. Form

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

Steps in Achieving Esthetic Complete Denture:

1- An accurate impression
2- Jaw relation
3- Selection of teeth
4- Arrangement of teeth
5- Characterization

1- An accurate impression
Thickness of labial flange of both dentures, this is accomplished at the
impression phase of treatment, so that the esthetics as well as retention
and stability are important goals. Border thickness should vary with the
needs of the patient, depending on the extent of residual ridge loss. The
vestibular fornix should be filled, but not overfilled, to restore facial
contour.
2- Jaw relation
Amount of separation between maxilla and mandible, this is
establishment of the correct vertical dimension of occlusion; proper
vertical dimension of occlusion helps restore normal physiological length
to muscles and allows normal facial expression.
Reestablishing the appropriate vertical spacing will improve the patient’s
appearance by decreasing the sunken and aging appearance. This vertical
space must be not only esthetically pleasing but also compatible with the
typical mandibular joint apparatus, including the muscles of mastication.

3- Selection of teeth
Teeth selection is very important as the selection of the appropriate shade,
size, and form of the artificial teeth determines the esthetic and function of
the denture.

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

Objectives of Tooth Selection:

1. Function efficiently.
2. Normal speech.
3. Aesthetically pleasing.
4. No tissue abuse.
5. Should maintain the vertical dimension.

Anterior teeth selected primarily to satisfy esthetic while posterior selected

for function.

Guides for Anterior Teeth Size:

Pre-extraction records:
Diagnostic cast, photograph, radiograph, extracted teeth and previous
denture.
Post extraction records:
1.Central incisors restore philtrum if possible.
2.Central incisors restore vermillion border.
3.Incisal points and smile line determine height of tooth (age-related).
4.Position of canine points
A. Relate to inter-alar width (smiling).
B. Relate to pupils (require pre-extraction photograph).
5. If patient is already a denture wearer, the mouth should be examined
with the dentures in the mouth giving importance to physiological and
esthetic aspects.

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

Factors of Selection of Anterior Teeth

1. Color / Shade
Show your patients a complete shade guide and select the two
lightest and darkest tabs. Point out how different these two are and
find out which one they prefer. Delete the rejected color, and select
another shade from the preferred half of the shade guide. Repeat this
pair comparison, and after two or three selections by your patients,
you will have the shades that they want. Note the selections used in
your file.

2. Size depends on:

a. Existing dentures.
b. Models of previous teeth.
c. Photograph

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

All of above give valuable input for selection of the size and shape of
teeth. Teeth can be measured in millimeters and teeth of similar size
selected coupled with actual measurement,
again use a method of pair comparison to assist
patients to decide what size of tooth they prefer.

Factors that influence the size of anterior teeth are:

1. Size of the face.
2. Amount of available interarch space.
3. Measured distance between distal of right and left maxillary cuspids.
4. Length of the lip.
5. Size and relation of arches.

3. Mold
Select and agree on the mold of the teeth. Teeth of a similar size can
appear entirely different because of their taper, contacts, and labial
curvature. Allow your patient to select between molds of the same size
but different shapes. Set two different molds on the right and left sides of
a piece of wax rope and ask patients which they prefer.

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

There is a choice of mold: square, tapering or ovoid. In general terms,

square molds suit patients with large, rugged features. Long and narrow
faces may be best suited to tapering molds, whereas ovoid molds tend to
suit patients with small, round faces.

Form of the Anterior Teeth

The form or outline of the anterior teeth can be determined using the
following factors:
1. Shape of the patient’s face or facial form (previously mentioned).
2. SPA factors (sex, personality, age).

Sex: The form or shape of the teeth differs in males and females. The
differences in the shape of the anterior teeth in males and females are:
• In females, the incisal angles are more rounded and the teeth have a
lesser angulation. In males, the incisal angles are rounded to a lesser
degree and the teeth are more angular.
• The incisal edge of the central incisors is parallel to the lips and the
laterals are above the occlusal plane in males. But the incisal edges of the
central and lateral incisors follow the curve of the lower lip in females.
• The distal surface of the centrals is rotated posteriorly for females.
• The mesial surface of the lateral incisors is rotated anteriorly in relation
to the centrals in females.
• In males the mesial end of the laterals is hidden by the centrals. This
makes the canine very prominent in males.
• Only the mesial thirds of the canines are visible in females because they
are rotated anteriorly whereas even the middle two-thirds of the canines
are visible in males.
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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

• The cervical regions are more prominent in males than in females.

• Females on smiling expose more anterior teeth hence, the premolars
should be arranged based on aesthetics for females.
Age: The age of the patient is important in teeth selection because of the
physiological and functional changes that occur in the oral tissues. The
patient can be either young, middle-aged or old-aged. The following
changes are observed with an advance in age of the patient:
• Due to decrease in muscle tone, sagging of the cheeks and the lower lips
occur. To prevent cheek biting (due to sagging), the horizontal overlap of
the posterior teeth can be increased.
• Inter-occlusal distance reduces with age. Hence, mandibular teeth are
more visible than the maxillary teeth.
• Old people usually have abraded teeth with worn out contacts. Hence,
placement of contoured teeth may look artificial.
• Old patients have gingival recession. It can be reproduced in the dentures
to provide a natural appearance.
• Old people show a blunt smile line and pathologic migration of teeth.
• The color of the teeth also changes with age. In old people, the enamel
is abraded and the dentine which carries a yellow tinge, is more visible.

Additional Clinical and Technical Considerations in Anterior Tooth

Selection Patient Preferences
A high smile line that displays a lot of gingiva would benefit from the
selection of a less tapered mold with a long contact point. This minimizes
the interproximal display of pink gingival acrylic, which is more difficult
to make look more realistic than teeth. The resultant smile ends up being
slightly more dental but with a less gingival display.

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

4- Arrangement of the Teeth

The goals of tooth arrangement are
1. To have the front teeth look good.
2. Allow the patient to speak clearly.
3. To have all the teeth positioned for the best comfort, stability and
retention of the dentures.

Position of the Teeth

The amount of tooth showing, orientation of the occlusal plane, and
labiolingual inclination all have an influence on aesthetics. If the level of
the occlusal plane is set too low, or if the anterior teeth are set on a flat
plane, then the teeth will be too visible. This will be emphasized when the
patient smiles, as the teeth will not follow the smile line of the lip. The
orientation will also have an influence, and if is not approximately parallel
to the interpupillary line, then the smile will look crooked. The center line
of the teeth is also critical, as this will have a negative effect on
appearance if it is not coincident with the center line of the face. The labial
frenum should not be used to guide positioning of the center line, as this
is often not in the center of the face. The labiolingual position of the
anterior teeth, in particular of the necks of the teeth, is critical in terms of
lip support. A common misconception is that lip support is reliant on the
shape of the labial flange of the denture. However, if the flange is
thickened, then this will cause bulking out beneath the nose similar to a
gum shield. If teeth are moved away from the crest of the ridge, then this
will cause instability of the denture. Setting teeth directly over the crest of
the ridge with an upright inclination will not provide adequate lip support.
As previously discussed, the use of biometric guides to place the teeth
where the natural teeth used to be can improve aesthetics dramatically. A
further possibility is to place the necks of the teeth close to the alveolar
ridge and tilt the incisal edges of the teeth labially. This will improve the

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

lip support and is less likely to be unstable than when using biometric
guides.

Arrangement of the Teeth with Esthetics Considerations

The clinician should attempt to create the illusion of natural teeth when
finalizing the appearance. It should be remembered that the prevalence of
irregularity or crowding of natural teeth is high. Therefore, if dentures are
constructed with a ‘perfect’ arrangement, the risk of the resulting
appearance seeming artificial is considerable.
As a general rule, imperfection in the anterior tooth arrangement is a basic
requirement in creating the illusion of natural teeth. Complete symmetry
should be avoided: for example, the anterior teeth should not be placed so
that the incisal edges are all at the same level.
The vertical axes of the anterior teeth can be varied, but if the inclination
of these axes on one side of the mouth does not approximately balance
that on the other, an unsatisfactory appearance will result.

Arrangement of the Lower Anterior Teeth

In many patients, they will be displayed more during function than the
upper teeth and therefore may be a dominant factor in determining the
patient’s dental appearance. Again, the same general rules regarding
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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

perfection and evenness of tooth arrangement which have been discussed

previously should be applied. The following should be considered when
arranging lower anterior teeth:
1. Vertical overlap.
2. Horizontal overlap.
3. Antero-posterior inclination in proximal view.
4. Inclination of long axes.

Incisal relationship
The method of determining an incisal relationship which is appropriate
for an edentulous patient’s skeletal relationship is important. If a patient
is provided with dentures which have an inappropriate incisal
relationship, for example, a Class I incisal relationship on a marked
skeletal Class II base, there is a risk that, in addition to problems with
stability, the dentures will lack in harmony and the aesthetic result will be
poor.

The Gingival Contour

There are three aspects to consider:
1. The contour of the gingival margins at the necks of the teeth.
2. The contour of the flange.
3. The color of the flange.
In a natural dentition, the contour of the gingival margin varies from
central incisor to lateral incisor to canine. This should be reproduced in a
complete replacement denture. In terms of the shape of the flange, the
clinician must decide whether to provide a flange with a smooth or

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

anatomical finish. In the case of the anatomical finishing, the dental

technician is instructed to:
1. Reproduce the shapes of the roots of teeth when contouring the flange.
2. The flange can also be stippled to reproduce stippling of the keratinized
gingiva.
These features are most useful when the patient has a high smile line and
is likely to have a visible flange. A potential problem with anatomical
contouring is the difficulty in keeping the flanges clean, particularly when
extensively stippled.
3. Finally, the appearance of the oral mucosa can be reproduced using
color tints in the acrylic resin. This is time consuming for a dental
technician and will be facilitated by the technician seeing the patient or a
photograph of the oral mucosa. Nonetheless, the appearance of the
denture will be enhanced if the flange is visible due to a high smile line.

Denture base factors:

1. Contour

2. Colour

Benefits of Properly Contoured Dentures:

✓ Improved tolerance and comfort

✓ Facilitates stability and control
✓ Prevents chronic biting of the lip or cheek

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

5- Characterization
To alter by application of unique markings, indentations, coloration and
similar custom means of delineation on a tooth or dental prosthesis thus
enhancing the natural appearance.
Characterizing the dentures without deviating grossly from the principles
of teeth setting to suit the individual’s appearance. The possible effect is
that all dentists may give almost identical complete dentures to their
patients. All complete denture wearers were looking similar possessing a
monotony of sameness. They understandably do not ask for what they
don’t know. It is the duty of the dentist to inform the patient that his/her
complete denture can be characterized to suit his/her wish and appearance.
Characterization helps the dentist to incorporate his artistic skills along
with theoretical knowledge in the fabrication of denture. Size and shade
of the teeth can be selected to match the patient’s natural teeth. The aim
is that the teeth should harmonize with the facial features, and it should
be functionally acceptable. Characterization should have some amount of
realistic perception rather than incorporating unrealistic features.
According to Frush and Fisher dentogenic concept includes effects of
three main factors such as age, sex and personality in sequence of esthetic
planning. Various means like minor irregularities in tooth arrangement,
overlapping, tilting, depth grinding, modification of incisal edges,
rotations of teeth, stippling, staining, tinting of the denture base, crowding
and fixing dental jewelry etc., can be incorporated depending on patient’s
desire towards achieving natural illusion.

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 Esthetics in CD Prosthodontics Dr. Mohammed Hussein
M. Alsharbaty

Final Decision for Esthetics Depends Upon:

• Maxillomandibular relationships
• Patient’s appearance
• Patient’s mental attitude
• Functional requirements

Denture flanges mimicking gingival color

along with stippling

Tobacco staining on complete denture

Crowding and overlapping of the maxillary

anterior teeth

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