Anterior teeth selection

Dr Priyam Javed

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2. ANTERIOR TEETH SELECTION FOR COMPLETE DENTURE PATIENTS 2

3. CONTENTS 3 Introduction Objectives of teeth selection Anterior teeth selection Size Form Shade and color Size of face Winklers concept Pounds concept Form Dentogenic concept

4. Patient preferences Selection of material Discussion Summary References 4

5. INTRODUCTION 5

6. OBJECTIVES OF TEETH SELECTION Functional efficiency Normal speech Aesthetically pleasing No tissue abuse Maintenance of the vertical dimension 6

7. Evolution of techniques 7 Young in 1954 described the evolution of various techniques used in the selection of anterior tooth mold. Technique 1 During the ivory age and early porcelain period ,teeth were selected or created mostly by dimensional measurements of the denture space and arch size with little regards to aesthetics. ( Heartwell C.M,Rahn A.O(1986).Syllabus of complete dentures,4th Ed.Lea and Febiger,Philadelphia )

8. Technique 2 8 The "temperamental technique" was the first technique of selecting tooth form from the point of view of influence and universal acceptance.It required several years to associate and establish dental characteristics of the temperaments and to incorporate them in manufactured tooth forms.This occurred by 1885. ( Wright W.H (1936).Selection and arrangement of artificial teeth for complete dentures.Journal of American Dental Association,23,2291)

9. Technique 3 9 The "typal form" concept projected by W.R Hall in 1887.This was the initiation of the geometric theory later presented by Williams.The basis of this classification was mainly on the labial surface curvatures,outline form and neck width.Hall gave the classification of overall tapering and square. ( Hayward D.E (1968).Use of natural upper teeth in complete dentures.J.Prosthet Dent 19,359)

10. Technique 4 10 Berry's biometric ratio method-1906.Berry investigated the correlation between face form and tooth form and resulted in the discovery that the maxillary central incisor was 1/16 the width of the face and 1/20 its length.Difficulty in practical applications discouraged the use this technique. ( Mavroskoufis F et al (1981).Nasal width and incisive papilla as guides for the selection and arrangement of maxillary anterior teeth.J.Prosthet Dent 45,592 )

11. Mavroskoufis et al in 1981 concluded that the interalar nasal width is a reliable guide for selecting the mold of anterior teeth.The authors advocate that the tips of the canine be set on a line which passes through the posterior border of the incisive papilla which proved to be a stable anatomic landmark.The incisive papilla can also be used as a guide for arranging the labial surface of the central incisors at 10 mm anterior to the posterior border of the papilla. 11

12. Technique 5 12 "Clapps tabular dimension table method"-1910.Teeth were selected based on the overall dimension of six anterior teeth arranged on the Bonwill circle and the vertical tooth space available in the patient. ( Clapp G.W (1995).How the science of aesthetic tooth form selections made easy .J.Prosthet .Dent.5,596)

13. Technique 6 13 Valderrama's "Molar tooth Basis" was projected in 1913.This method of only historical value used varying measurements between combinations of cusp points to indicate the size of the individual and overall tooth measurements.The basic problem with this technique is that edentulous patients have no molars.

14. Technique 7 14 Cigrande in 1917 advocated the use of the outline form of the fingernail to select the outline form of the upper central incisor.The size was modified to meet the requirements of tooth space and other relationships. (Fenn,Lidelow,Gimson (1989).Clinical Dental Prosthetics,3rd Ed,Wright.)

15. Technique 8 15 The geometric method or Law of Harmony.Williams "Typal form method" projected by J.Leon Williams in 1914 is based on the geometric pattern created by the outline form of the bony face frame-the ovoid,square and tapering forms.William arrived at this classification after extensive anthropological study.This method is probably still the way in which most dentists select anterior artificial teeth.

16. Technique 9 16 "Maxillary arch outline form " projected by Nelson in 1920.This technique assumed that the arch outline form was a valid method since it was related to an individuals anatomy.This was invalidated by changes in arch form due to resorption.

17. Technique 10 17 "Wrights Photometric method"proposed in 1936 was based on using a photograph of the patient with natural teeth and establishing a ratio by comparative computation of measurements of like areas of the face and photograph.

18. Technique 11 18 "The multiple choice method" introduced by Myerson in 1937 was based on a need for a selective range in labial surface characteristic of transparent labial and mesial surfaces ,varying surface colour tone,and characterization of teeth by time and wear. ( K e r n B . E ( 1 9 6 7 ) . A n t h ro p o m e t r i c p a r a m e t e r s o f t o o t h selection.J.Prosthet.Dent.17,431)

19. Technique 12 19 "Anthropometric-Cephalic index method" projected by Sears in 1941 was based on the fact that the width of the upper central incisor could be determined by dividing either the transverse circumference of the head / 13.

20. Technique 13 20 "Bioform technique" proposed by the Dentists Supply company in 1950 is based on the geometric outline forms of face and teeth -the "House" classification for 4 Basic and 3 combination Typal forms,and 3-dimensional harmony of tooth form and face form.It is associated with the tabular and mold guide systems and is currently in use. ( Hickey J.C,Zarb G.A,Bolender C.L (1985).Bouchers prosthodontics treatment for edentulous patients,9th edition,Mosby,S.Louis)

21. Technique 14 21 The "Trubyte tooth indicator" or "Selection indicator instrument" method advocated by the Dentists supply Company which is correlated with Williams and House's Typal form theory and the Tabular technique.

22. Technique 15 22 House instrumental method of projecting Typal outline and profile silhouettes onto the face by means of a telescopic projector instrument and silhouette form planes.This was correlated with designated mould numbers and size variation.This was proposed by House in 1939 and by the Dentists Supply Company in 1950.

23. Technique 16 23 "Automatic instant selector guide" of the Austenal company in 1951 correlated form,size and appearance in such a manner that only a single reading was required to select the appropriate tooth mould based on dimensions of denture space and harmony of face and tooth form.

24. The Golden proportion 24 If we study the beauty of nature,teeth or art,we will discover a common principle running throughout.This common principle is the universal recognition of pleasant proportion of 1.618:1.A constant ratio between the larger and smaller length. In terms of proportion,the smaller tooth is about 62% the size of the larger one.This had been offered as a corner stone of smile design theory.

25. CONCEPTS IN SELECTING 25 THE SIZE OF THE ANTERIOR TEETH

26. WINKLERS CONCEPT Biological - phys i o l og ica l Biomechanical Psychological 26

27. Biological Physiological 27

28. Prope r understandin g o f th e facia l musculature,norma l facia l appearance,physiological parameters. A prop e r im pr e ss i on pro ce dure -w it h f i n a l ca st t h a t h a s acc ur at e representation of the vestibule and other remaining structures. In older patients there is a loss elasticity of the facial musculature.There is a tendency to plump out the face with additional thickness of denture base material. Another approach to reduce wrinkles-increase the vertical dimension. Adverse effects??? 28

29. Biomechanical 29

30. "On the ridge" or "How far off the ridge?" 30 In g e n e r al -p lac e t he a n te r i or teet h a s cl os el y i n r elati on t o t he residual ridges as were the original natural teeth…. Fish states that"there is no exception to the rule of replacing the natural teeth by setting the artificial ones in exactly the same relation to the body of the maxilla unless the patients appearance will be improved by some slight modification".

31. "The proper position for the tooth is not necessarily on the r i dg e , i ns i de t he r i dg e ,or ou t s i de t he r i dg e ,but a t a po i nt where the tongue and cheek pressures balance" 31

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33. The Psychological view-point 33

34. Broad smile-positive self evaluation Tight lipped small smile-negative self evaluation. 34 • • • • Unsure hesitant qu e s ti on i ng introverted Campers plane - psychological plane of orientation This,t o a certai n exten t ha s a n e f fec t i n determinin g th e appearance of a patients psychological state.

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36. Selection of Anterior Teeth Factors affecting are: Size of the teeth Form of the teeth Colour/shade of the teeth Additional clinical and technical considerations 36

37. 37 Size of the anterior teeth Size of the face. Size of the maxillary arch. Incisal papilla and the cuspid eminences or the buccal frenum Maxillomandibular relations. The contour of the residual ridges. The vertical distance between the ridges. The lips.

38. Size of the face Average width of maxillary central incisor =1/16th of the width of the face measured between the zygoma. Combined width of the 6 maxillary anterior teeth =slightly less than 1/3rd of the bizygomatic breadth of the face. Width of maxillary central incisor =length of the face/20 T he T ruby t e t oo t h i nd icat or ca n be us e d t o mea sure t he s iz e of t he maxillary central incisors. 38

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41. POUNDS CONCEPT 41 Tooth width by measuring the distance from zygoma to zygoma. Width of central incisor =bizygomatic width /16 Total width of anteriors=bizygomatic width /3.36 Total width of lower anteriors =4/5 th width of upper anteriors Length of the central incisor =length of the face/16 Width of upper central incisors=circumference of the head/13 (Sears concept)

42. Size of the maxillary arch The mold selectors are used to make measurements of the maxillary cast. Make measurements from crest of the incisive papilla to the hamular notches and between the two hamular notches.The combined length of the 3 legs of the triangle in millimetres is used. 42

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44. Shivrayan A et al (2013) had done a study on the relationship between pterygomaxillary notches, maxillary anterior teeth and the Dental arch. The study was conducted on 70 individuals. All the measurements were taken directly on the casts with a precise digital caliper. Interhamular width and distal maxillary arch width were found to be almost equal to sum total mesio distal dimension of maxillary anterior teeth. Interhamular width remains the same dimension during lifetime; as it does not undergo alveolar bone resorption. Relationship between pterygomaxillary Notches, Maxillary Anterior teeth and Dental arch: An Invivo study. National Research Denticon 2013; 4:294- 302. 44

45. Incisal papilla and the cuspid eminences or the buccal frenum A flexible ruler is used and the distance between the 2 canine eminences at their distal side is measured in millimeters.This measurement gives the combined width of the 6 anterior teeth. Another method is with the occlusal rim.The vertical line drawn from this mark coincides with the pupil of the eye.The distance between the marks following the contour is the total width of the anteriors. 45

46. H a rp e r w a s t he f i rst t o d e s c r i be t he i n ci s i ve p a p ill a a s a gu i de i n d e n t ure prosthetics in determining the labial extent of the central incisors. 46 Schiffman studied 507 maxillary casts of dentate patients. An imaginary line passing through the tips of the cuspids was found to be within 1mm of passing through the center of the incisive papilla in 92.1% of all the casts. Harper RN: The incisive papilla.J Dent Res 1948;27:661-668 3I. Schiffman P: Relation of the maxillary canine to the incisive papilla.J Prosthet Dent 1964;14:469-472

47. Maxillomandibular relations Any disproportion in size between the maxillary and the mandibular arches influences the length ,width and position of the teeth.This is of importance in class II and class III maxillomandibular relations. 47

48. The contour of the residual ridges The artificial teeth should follow the contour of the residual ridges that existed when natural tooth were present.With resorption ,there is alteration in the contours of the ridge.As resorption occurs,because of morphology,maxillary arch appears smaller and the mandibular arch appears larger. 48

49. Vertical distance between the ridges The length of the teeth is determined by the available space between the existing ridges.It is advisable to use a tooth long enough to eliminate the display of the denture base. 49

50. The lips This guides the selection of the length of the maxillary anterior teeth .At rest,the labial surface of the maxillary anterior teeth should support the upper lip.In speech,the incisal edges of maxillary anterior teeth should contact the lower lip at the junction of the moist and dry surfaces of the vermillion border ,when the patient pronounces 'f'. 50

51. Inner canthal distance, interpupillary distance, intercommissural distance, distance between the tips of the maxillary canines and distance between the distal surfaces of the canines were measured. On the cast, the distance between tips of maxillary canines and distance between distal surfaces of maxillary canines were noted. Extra oral anthropometric measurements of the interpupillary distances and the intercommissural distances with the help of standardised photographs can help us determine the combined widths of the anterior teeth accurately, thus aiding their selection in the absence of pre-extraction records. Kini AY, Angadi GS.Gerodontology. 2013 Jun;30(2):105-11 51

52. The following 6 measurements were recorded for each set of casts: left mid- maxillary to right mid-maxillary, representing the distance between the respective residual ridge crest points adjacent to each canine eminence; left retromolar pad to right retromolar pad; incisive papilla to left hamular notch; incisive papilla to right hamular notch; left hamular notch to right hamular notch; and incisive papilla to vibrating line. These measurements were statistically compared with the control, the canine-to-canine distance as marked on the contoured maxillary occlusion rim to indicate the relaxed commissures. Based on the results of this study, use of the right hamular notch to left hamular notch measurement plus 10 mm provides a useful method for determining the width of the 6 maxillary anterior teeth for complete denture patients. J Prosthet Dent 2010;105: 44-50 52

53. Form of anterior teeth Form and contour of the face D e n t og e n i c concept 53 Pr e - e x t r acti on records

54. T he sh a pe of t he a r ti f icia l t oo t h shou l d h a r m on i se w it h t he patients facial form. Leon Williams-shape of upper incisors is the shape of the face- most useful guide. Leon classified shape of face into 3- square tapering ovoid 54

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56. Facial Profile Forehead Base of the nose Prominent point of the chin 56

57. Dentogenic concept Frush and Fisher(1957) Teeth are selected and arranged Sex 57 Personality Age

58. Sex of the patient 58 Curved facial feature-More feminity Square features-Masculinity Teeth of females are more ovoid or tapering than square. However,the form of the teeth will vary as the features vary.

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60. In females, 60 Incisal angles are more rounded The incisor edges of the central and lateral incisors follow the curve of the lower lip The distal surfaces are rotated posteriorly in females Only the mesial thirds of the canine are visible in females since they are rotated anteriorly.

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62. In males, The incisor edge is parallel to the plane and the laterals are above the occlusal plane. T he la b ia l surf ace s of ce n t r a l i n ci sors a re not usu all y rotated In males,the mesial ends of the laterals are hidden by the central .This makes the canine very prominent. The middle two thirds of the canines are visible in males. 62

63. Age The following changes are seen as age advances Due to decrease in muscle tone,sagging of cheeks and lower lip occurs.. To prevent cheek biting (due to sagging),the horizontal overlap of the posterior teeth can be increased. Interocclusal distance reduces with age.Hence,mandibular teeth are more visible than the maxillary teeth. Teeth abrade with age.The cuspids abrade in a curve. The abrasion of incisal edges flattens with the arch,fullnessof the lower lip diminishes. 63

64. G i ng i v a l ti ssu e s r ece de w it h a g e .It ca n be r e produ ce d i n d e n t ur e s t o provide a natural appearance. T he s mili ng li ne i s sh a rp i n young p e op l e a nd le ss e r sh a rp i n o l d e r people with pathologic migration of teeth. T he c o l or of teet h al so c h a ng e s w it h a g e . T he e n ame l i s a br a d e d a nd the dentine which carries a yellow color is more visible. 64

65. Personality Delicate 65 Medium pleasing V i gorous

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67. 67 Role of individual teeth in personality interpretation Central incisors -contribute to desired strength and action of the smile. Lateral incisors -being subordinated in position to the central i n c i s o r s - h a r d n e s s a n d s o f t n e s s , a g g r e s s i v e n e s s o r submissiveness,vigorous tendency or delicate tendency of the patient. The cuspids must dominate the lateral incisors in color,form and position.

68. A s t udy on t he ae s t h eti c c ons i d e r ati ons i n t he s electi on of teet h for 68 complete denture patients. Pre extraction records which included diagnostics casts, recent photographs and radiograph of the teeth were taken. Post extraction examination included; size and form of edentulous arch, if patient wore dentures; then should be examined in the mouth giving importance to physiological and aesthetic aspects. The factors influencing the size and former the anterior teeth are; size of the anterior teeth; form of the anterior teeth; color of the interior teeth. Dentogenic factors included sex factor, personality factor, and Age factor. They concluded that selection of teeth mainly depends on the type of patient and the condition of supporting tissues. Ahmad I. Anterior dental aesthetics: Facial prospective.Br.Dent.J 2005; 199:15- 21.

69. Pre extraction records 69 Facial photographs-width and outline forms Diagnostic casts Radiographs Teeth of close relatives Extracted teeth-size and form

70. Colour or shade of anterior teeth 70 The age of the patient The individual complexion pattern The patients desires The colour of hair and eyes Habits of the patient

71. Co l our Hue 71 V al ue Chro m a Hue -specific color produced by a specific wavelength.It should be in harmony with the patients skin color else it will look artificial. Value -lightness or darkness of the object.It is the dilution of a color with either black or white to produce darker or lighter shades respectively. Chroma -The amount of color per unit area of an object.It denotes the intensity of the color.

72. W h e n a t oo t h i s v ie w e d from d ete r mi n i ng it s c o l o r -2 principal colors Yellow-more prominent in the gingival third Grey-More prominent in the incisal third 72 Hue of the tooth is actually the quality the dentist tries to duplicate.

73. Colour of hair,eyes and skin 73 Blue,green or light coloured eyes with fair skin-lighter shade teeth Black or dark eyes-darker teeth

74. Age With increasing age -progressively darker Attrition at incisal edge-decreased translucency with age More shiny as age advances-regular wear of teeth Brownish tinge-exposed dentin tends to stain 74

75. Selecting color 75 Place the shade tab in the following areas Along the side of the nose-establishes basic hue,value and chroma Under the lips with only the incisor edge exposed-reveals the effect of color of teeth when the patients mouth is relaxed. Under the lip with only the cervical end covered and mouth open- simulates the exposure of teeth as in smile.

76. Squint test Evaluates colour of the teeth with complexion of the face. Eyes are partially closed to reduce light ,dentist compares the selected shade tabs by holding them along the face of the patient.The color that fades from the view first is the one that is least conspicuous and is in harmony with the color of the face. Whenever possible-record the size,form and colour of the natural teeth before extracting them. 76

77. Additional clinical and technical considerations Patient preference Highly visible gingiva Limited interocclusal space Opposing natural teeth 77

78. The personal touch-Characterization of selected teeth Teeth can be modified to create a personal smile in a number of ways and combinations such as Changes in color and position Individual grinding and placement Placement of restorations and worn appearance 78

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81. SUMMA R Y 81

82. 82 TEXTBOOK REFERENCES Heartwell.C.Syllabus for complete dentures.4th edition. Za ra Bo le nd e r , Ec k e r t ,J ac ob.Pros t hodon ti c t r eatme nt for e d e n t u l ous patients.12 th edition. Winkler S.Essentials of complete denture prosthodontics.2nd edition. Rahn Arthur.textbook of complete denture.BC Decker.6th edition RM Basker,JC Davenport.Prosthetic treatment of edentulous patient. Sharry J.J.Complete denture prosthodontics.Mc Graw Hill.3rd edition.

83. 83 JOURNAL REFERENCES W r i ght W .H (1936).S electi on a nd a rr a ng eme nt of a r ti f icia l teet h for c o m p let e dentures.Journal of American Dental Association,23,2291. M. Vasantha Kumar Science of Anterior Teeth Selection for a Completely Edentulous Patient: A Literature Review .J Indian Prosthodont Soc (Jan-Mar 2011) 11(1):7–13 Harvard D.E (1968).Use of natural upper teeth in complete dentures.J.Prosthet Dent 19,359 M a vroskouf i s F e t a l (1981).N a s a l w i d t h a nd i n ci s i ve p a p ill a a s gu i d e s for t he selection and arrangement of maxillary anterior teeth.J.Prosthet Dent 45,592 C la pp G.W (1995).How t he s cie n c e of ae s t h eti c t oo t h form s electi ons ma de easy .J.Prosthet .Dent.5,596 Kern B.E (1967).Anthropometric parameters of tooth selection.J.Prosthet.Dent. 17,431 H ic k e y J.C, Za rb G.A,Bo le nd e r C.L (1985).Bou c h e rs pros t hodon tic s t r eatme nt for edentulous patients,9th edition,Mosby,S.Louis

84. 84 Shivrayan A.Relationship between pterygomaxillary Notches, Maxillary Anterior teeth and Dental arch: An Invivo study. National Research Denticon 2013; 4:294- 302. Kini AY, Incisal papilla as a guide in teeth selection.Gerodontology. 2013 Jun;30(2): 105-11 Ahmad I. Anterior dental aesthetics: Facial prospective.Br.Dent.J 2005; 199:15- 21. Baker .Denture cast measurements in anterior teeth selection.J Prosthet Dent 2010;105: 44-50 Harper RN: The incisive papilla.J Dent Res 1948;27:661-668 3I. Schiffman P : Relation of the maxillary canine to the incisive papilla.J Prosthet Dent 1964;14:469-472

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