Michael Waliszewski (J Prosthet Dent 2005;93:386-94.) Restoring dentate appearance: A literature review for modern complete denture esthetics Michael Waliszewski (J Prosthet Dent 2005;93:386-94.)

Complete denture fabrication techniques, while not universally standardized, have resulted in a high degree of success. In contrast to the recent success in addressing comfort and function, restoring an edentulous patient’s appearance has received little attention in the modern prosthodontic literature.

Esthetics versus function Carlsson et al found that esthetics was the factor most responsible for complete denture success. Liefer et al had statistically significantly fewer adjustment appointments and a greater number of pleased patients when all esthetic decisions were made by the patient. This implies that when the esthetic result was successful, the dentures were more successful overall.

Vig agreed with the importance of esthetics in denture success, stating that, ‘‘Good appearance is so related psychologically to comfort that the two cannot be separated.’’ A survey by Vallittu et al found that patients wearing removable dentures considered the appearance to be the most important property of the teeth.

Brewer demonstrated through a limited clinical trial that denture patients almost exclusively chose the more esthetic denture over the denture with better comfort or function.

Early concepts—temperamental and typal White introduced what is probably the first esthetic concept when he described his theory of correspondence and harmony. White described this theory as a correspondence between tooth form and color in harmony with age and gender. This was later accepted as the temperamental theory of denture construction.

It was based on the idea that a subject’s temperament or bodily characteristics matched the size, proportion, arrangement, and color of the teeth. Some interesting ideas highlighted by this early esthetic concept included (1) the relationship between age, gender, and appearance, (2) the proper tooth-to-face-size proportion, and (3) color harmony between face and teeth.

The inability to agree on a specific prosthetic tooth for a certain temperament or to decide which temperaments existed limited this system’s practical usefulness.

Hall was the first to describe what he believed was a correlation between face form and tooth form. The argument for what became known as the typal form concept of esthetics was based largely on Williams’ own anthropologic research. He stated that 3 basic forms of teeth existed: square, tapering, and ovoid. These were termed the typal forms of teeth. The system succeeded due to its practicality and manufacturer support and not because of any actual relationship.

Using the typal form concept clinically is complicated by facial form appearance alterations due to age, hairstyle,eyewear, and body mass changes.

As details of denture construction continued to be investigated, emphasis switched from tooth selection to tooth arrangement. Nelson was the first to assert that tooth arrangement was the major determinant of tooth-mold appearance and more important to the overall esthetics. Sears, Richey, and French built on this concept.

Dentogenics Frush and Fischer used the early ideas of Sears to help establish the dentogenic concept of denture construction. These authors wrote that gender, personality, and age could be used as guidelines for tooth selection,arrangement, and characterization to ‘‘enhance the natural appearance of the individual.’’

Modern concepts—patient involvement and preference The next advancement in denture esthetics was an article on the principles of visual perception detailing the use of standard artistic principles. The primary guideline is to attempt dynamic unity, also called unity with variety. The entire dental composition should be complimentary to the face and to itself. At the same time, it should not be mechanically straight or without uniqueness. Proportion, line, dominance, balance, and color are some of the specifically applied principles.

If the patient is involved in esthetic decisions, patient preference for certain attributes becomes important. If the dentist understands what the patient prefers, the chances for miscommunication are likely to be decreased.

Dentate patient research Husley determined that the most attractive smiles had teeth that followed the lower lip line, displayed the entire length of the maxillary central incisor without gingival display, and were symmetrical.

Three esthetic concepts Natural Supernormal Denture look

Concept Definition Description Source of information Natural Appearance in accordance with or determined by inherent character or basic constitution of person Use of artistic determinants of personality and anatomic norms for gender and age to achieve harmony with overall appearance Studies of natural dentition averages. Published guidelines of clinicians Super normal Appearance that departs from what is usual or normal, especially so as to appear to transcend laws of nature Alterations from anatomically normal to provide subject with what he/she regards as beautiful Patient preference studies Denture Look Appearance that befits or accords with set of false teeth Appearance with errors in tooth display, shape, size, and arrangement that are typically seen in complete denture wearers Published guidelines of common visual errors

Natural Appearance in accordance with or determined by inherent character or basic constitution of person. Use of artistic determinants of personality and anatomic norms for gender and age to achieve harmony with overall appearance

Super normal Appearance that departs from what is usual or normal, especially so as to appear to transcend laws of nature. Alterations from anatomically normal to provide subject with what he/she regards as beautiful

Denture Look Appearance that befits or accords with set of false teeth. Appearance with errors in tooth display, shape, size, and arrangement that are typically seen in complete denture wearers.

Universal esthetic goals A 100-degree nasolabial angle and a 140-degree mentolabial angle should be the goal for the extraoral appearance in a white population. The incisal edges of the maxillary teeth should follow the lower lip line, and a reverse curve should be avoided. The dental midline should be both coincident with the facial midline and vertically straight. A gingival-to-lip distance of 4mm or more may be considered unesthetic. These factors should be considered baseline esthetic guidelines in complete denture construction. Specific decisions about tooth display, proportion, size, shape, arrangement, color, and, to some extent, position are based on which esthetic concept the patient and dentist have chosen.

SUMMARY The goal of this literature review was to organize the available esthetic literature to determine when and if clinicians may apply certain information. This review demonstrated that 3 esthetic concepts for complete denture fabrication exist. To use the information gathered to date, some critical questions remain. Do edentulous patients seek a different oral appearance than dentate patients? If they do, what is the preferred appearance? If these 2 questions can be answered, at least in part, then the application of current knowledge can be validated.