Esthetics in complete denture

The seminar includes- Introduction, definitions, history, Fundamentals of esthetics, Incorporation of Esthetics at different stages of complete denture construction, Dentogenic concept, Dynesthetic interpretation of dentogenic concept, Denture characterization and newer studies

1. Esthetics in complete denture Presented by- Dr. Priya Gupta (MDS II yr )

2. Contents:- Introduction Definition 3 . Review of literature 4 . Fundamentals of esthetics 5 . Impression making 6 . Jaw relation 7 . Anterior tooth selection Dentogenic concept Dynesthetic interpretation of dentogenic concept SPA factor

3. 8 . Anterior and posterior teeth arrangement 9 . Characterization of denture 10. Errors in esthetics 11. Summary 12. References

4. Introduction:- Frush ’ states, “The acceptance of treatment by the patient is made considerably easier when the prosthesis accomplishes two basic esthetic needs: the portrayal of a physiologic norm an actual improvement in the attractiveness of the smile Esthetics goes much further than the simple placement of teeth in occlusion rims . The dentist must consider both the anatomy and physiology of the face, as well as artistic principles, to achieve a natural looking denture. Beauty lies in the eyes of the beholder. W e greet the world with our faces .

5. Definition:- Glossary of Prosthodontic Terms - Esthetics can be defined as the branch of philosophy dealing with beauty . Descriptive of a specific creation that results from such a study: objectifies beauty and attractiveness and elicits pleasure. Denture esthetics : the effect produced by a dental prosthesis that affects the beauty and attractiveness of the person.

6. History G.Fonzi an Italian dentist in Paris invented the Porcelain teeth that revolutionized the construction Of dentures In 1937 Dr. Walter Wright introduced resin . 6

7. Review of literature:- John P Frush And Roland D Fisher in 1955 They introduced the word “ dentogenic ” in prosthetic dentistry to ease the selection of anterior teeth in complete denture prosthodontics. Factors of Dentogenic restorations, sex, age, and personality has improved appearance of the denture wearer. 

8. Donald F K in 1956 studied relation between the denture esthetics and denture base . The factors relating to the denture base are the reproduction of the contours of the tissue covered by the base, and its staining to reproduce the natural tissue hues. Indications for esthetic denture bases in patients with active upper lip, patient with prominent premaxillary area, theatrical performers and singers, produces psychologic effect on the patient

9.   Frush and fisher in 1958 , they studied the qualities of femininity, masculinity, personality and the various physiologic ages in smile. Richard E. lombardi in 1973 ,he studied the science and principles of visual perception and their influence in creating intense vitality, beauty , and realism on denture prosthesis. By application of Dynesthetic techniques to the Dentogenic concept have accomplished the pleasing personality, masculinity, and femininity, effectively. P rinciples of esthetics such as unity, composition, dominance, proportion, illusion in denture esthetics .

10. Composition: The increase of visibility is proportional to the increase in contrast. The relationship between objects made visible by contrasts is called composition . Contrast: It is that factor which makes the various elements of a composition visible. The eye can differentiate the parts of an object due to contrast of colors , lines, patterns, textures, etc.

11. Unity:- Prime requisite of composition It is the ordering of the parts of a composition to give the individual total effect of “whole”. Unity between different parts of the face, and teeth is essential to give the effect of oneness or wholeness to the dento - facial composition It is of two types Static unity Dynamic unity Structures with regular 1. Plants and animals geomtric shapes. eg snowflakes & crystals 2. Passive and inert 2. Active living and growing 3. Fixed , without motion 3. Crescendo approaching a climax

12. Elements which unify a composition are cohesive forces and elements which lend disunity are segregative forces. Cohesive forces - Repetion of shape, color, line -Arrangement of the elements of a composition in a definite pattern -Arrangement of the elements according to a principle -presence of a border.

13. Unity with variety (segregate force)- Necessary to make design effective The elements must be bound together in an interesting manner Segregating forces are represented by elements arranged in an appealing manner, reminders of an interesting thing or event such as class I tooth arrangement. Segregative forces are the necessary elements that enhance the esthetic value of a composition. A slight malposition, a reminder of a class II arrangement, conforms to this definition.

14. The greatest SIN against visual perception in denture esthetics –the placement of a static, dead denture in the most mobile and active of all the facial features in a living, dynamic, human being . Placement of anterior teeth on unchanging curve of a circle, lacks unity, because it does not give the patient the total undivided effect of a living being.

15. Sin against reality –teeth are set tight against the residual ridge so that when they are in the mouth, they appear to be too high and too far back in a position where they could not possibly be placed by nature . Objective of the dentist should be to provide Dynamic and not Static unity.

16. Hogarth’s Line of beauty Example of unity with variety is line inscribed around a cone. Line is never same at any point (absolute variety) along its course yet it never leaves the surface of cone (absolute unity) Adoption of a segment of this line for tooth placement and base festooning adds greatly to the dynamism of a set up. A line inscribed around a cone .It is never the same at any two points, yet never deviates from the principle of the cone structure. Absolute unity with absolute variety is provided.

17. Dominance:- Dominance one shape, color or line must dominate all the others. One tooth must dominate the anterior tooth arrangement by virtue of its size (central incisor is the logical choice) Unity Composition Prime requisite Prime requisite The dominance of size of the anterior teeth A weak dominance takes place when subsequent elements do not provide sufficient factors of contrast. A strong dominance requires the p resence of subsequent elements p roviding strong factors of contrast

18. The dominance of dental composition is increased by increasing mold size, using lighter teeth, placing the teeth farther anteriorly and increasing the exposed gingivoincisal length , are all method of increasing visibility. For a patient with soft personality , dominance may be produced by minimizing these factors and for a patient of strong personality all or part of the above features may be restored.

19. Symmetry:- It is the regularity of arrangement of forms either from left to right as in horizontal symmetry , or from a central point to either side like a mirror image as in radiating symmetry . The horizontal symmetry looks repetitive and uninteresting while the radiating symmetry looks dynamic and interesting . In a dento -facial composition radiating symmetry of the teeth is more esthetically appealing and is associated with youthfulness while horizontal symmetry is less appealing and is associated with aging.

20. Proportion:- The relationship of the various units which are different from each other in a composition but are associated with each other through a certain repetitive mathematical factor called as Repeated ratio . The proportion between the various elements of a harmonious composition, in which the cohesive and segregate forces are equally balanced and its various units in an esthetically appealing, respective proportion to each other is the Golden proportion. 

21. Dental esthetics and golden proportion (Edwin I. Lewin JPD 40;3, 1978 ) Golden proportion has been used since time immemorial It was extensively used in greek architecture eg the Parthenon on the Acropolis of athens .

22. Proportion between teeth In its simplest form it is the proportion between the larger part and smaller part . When ratio between B and A is in the golden proportion, then B is 1.618 times larger than A. The width of central incisor is in golden proportion to the width of the lateral incisor. Width of the lateral incisor to width of canine is also in golden proportion, as is the width of canine to first premolar. A B 0.618 1

23. Proportion between teeth and smile In the esthetically pleasing smile, the space between the corner of the mouth and the dental arch form a “backdrop” in which the anterior esthetic segment is featured. This segment is in the golden proportion to the width of the smile. The lateral negative space is in golden relationship with one half the width of the anterior segment

24. A common error in the construction of the complete denture is that this neutral space appears evenly full of teeth when the patient smiles, even to the extent of showing the molars. Unplanned prosthesis giving the so-called d enture look the space is too full and there is no tooth dominant at the corners of the mouth Planed prosthesis teeth appear to fade Evenly from central incisor to molar

25. Form of the corner of the anterior esthetic segment In any smile the central incisor dominate. The next dominant harmony should be in the region of canine or premolar. One of these teeth should be dominant to mark the corner of the mouth, and to stress the visual strength contained in the arch . The most difficult aspect of the prosthodontics is to establish the exact shape of the corner of the arch so as to be in complete harmony with the visual personality projected by the patient.

26. Illusion The front to back progression is a critical factor because illusion of arch shape and depth must be provided in the composition. If two like structure are placed at different distance on a line, the closest one to the viewer will appear larger. If other structure are placed in between the size reduction will appear to be gradual .

27. Buccal corridor helps achieve this gradation by altering the light. If two objects are the same size the lighter one appears larger, this is principle of illumination. As the teeth pass posteriorly, the light is reduced and this gives a gradually darker shade and therefore a smaller appearance. Principle of illumination, lighter one appear larger Teeth of equal width but different length appear to have different widths

28. Balance in denture esthetics The word denotes the stability resulting from equalization or exact adjustment of opposing forces . Balance suggests a steadiness that results when all parts are properly adjusted to each other, when no one part or constituting force is out of proportion to another . Induced forces- There is a desire on the part of the Beholder to see disk move towards A more stable position, it exhibits Induced force (visual tension) Disc seems more stable i n this position When a pair of discs are placed i t is the location of the center of t he pair which lends balance a nd stability to their placement

29. Structural map - the most stable position of the disc is in the center The proper midline location is a must for stability. Because of induced forces unbalanced things look transitory, restless, unfinished, accidental, temporary, aggravating, and tense . Proposed structural map of tooth area the most Stable position is at the intersection of the axes And indicates the critical role of the midline

30. Balanced things look permanent, stable, completed, planned, peaceful, and in repose , because the visual tensions are eliminated . Improper midline A measured midline Eye is a competent evaluator, the heavy Line in the middle is judged to be correct

31. Balance does not require symmetry. Formal balance means that things are same on both the sides . Informal balance means weight on either side of fulcrum are equal but not symmetrical. Balanced weight and direction must be achieved in a successful composition. Principle of illumination must also be considered when speaking of balance. Direction and wt must be balanced Lack of balance of direction is often The result of cross bite ridge relationship Imbalance results from altered direction Of midline

32. Line in denture esthetics:- Line is involved in - shape of the tooth - relationship between the adjacent teeth - between the teeth and the matrix - between the teeth and the background - between the teeth and the dark space area between upper and the lower teeth when the mouth is open Line is also involved in line formed by the incisal edges and buccal cusp tips of the teeth, in the occlusal plane, and the perspective illusion created by the total composition.

33. Shape of individual tooth is unimportant because of two other perception principle 1. primacy of the whole. The shape of the element becomes secondary to the shape of a series of the elements. The parts become a new whole. 2. presence of a border which binds the elements within into a separate entity. In dentistry, the wall (face) and frame (lips)are provided for us by nature. Attention of the eye is confined to the contents within the lips. Dimensions of the new whole created by the entire series The border unifies the Elements within it

34. Line in dental composition The strongest relationship that can exist between two lines is a perpendicular relationship because it exhibits greatest possible contrast . Most harmonious is parallel relationship , because it exhibits least possible contrast . The line relationship between adjacent teeth should be harmonious , that is striving towards parallelism and therefore harmony. The chief offender is usually the line formed by the distal outline of lateral incisor . The buccal surface of first bicuspid is a very close. Conflict of line

35. It is often necessary to reduce the distolabioincisal contour and the incisal third of the distal outline of the lateral incisor to eliminate the conflicting line. The neck of the lateral incisor may be kept out labially to minimize the line conflict. The line formed by the labial outline of the cuspid is especially important because it is close to the line formed by the lower lip as it curves upward towards the commisure , it completes the smile line. If the incisal edge is tipped lingually , the line formed by the labial surface of the cuspid is more nearly parallel to the line of the lower lip and exhibits a soft relationship.

36. As the cuspid is tipped more labially at the incisal edge it becomes more perpendicular to lip line and exhibits a strong relationship. If the incisal edges of the anterior teeth parallel the line of the lower lip as in the smiling line, a harmonious relationship exists. Cuspid Lip Relation-ship

37. The occlusal plane is another critical line and must be located in proper position. The plane must not be allowed to drop as it progress posteriorly to prevent sin against reality and beauty. The lines of the matrix at the gingival must be curved to prevent a sin against reality. The maxillary bite rim is built parallel to Camper’s line . Occlusal plane must rise as it progresses posteriorly

38. Negative space I t is the dark space of the mouth behind the teeth which is as important in the composition as is the positive space or the object being viewed. It is in altering the shape of the incisal edges contrasted against this black background that the dynamism and realism factor can be best analyzed for their effect. Negative space Static negative space Dynamic negative space Dynamic negative space

39. Color in denture esthetics Hue - characteristic of a color, eg Red, Yellow, Blue Intensity - amount of pigment in the color being described Value - lightness or darkness of a color Value in denture esthetics – The problem of matching is one of selecting proper value, not the proper color (hue). The selection of correct lightness or darkness results in successful shade selection.

40. Factors affecting color - amount of light striking the tooth - texture of the tooth, glaze (without glaze or convoluted surface, less reflection) - inciso -gingival angulation - background against which a color is seen (dark background makes color seem lighter) lighter tooth appears closer and vive-versa.(principle of illumination ) Shade selection Personality-1) strong, outgoing, vivacious, dynamic, zippy, indicator for a lighter shade 2) Weak, opposite of strong, darker shade 3) Average, between strong and weak

41. Skin color (background) - Dark skinned, shades adjusted downwards because background will make shade appear lighter - Light skinned- lighter Average- intermediate with age skin wrinkles and appear darker strong features require lighter teeth Heavy lipped individual with a low lip line require a lighter shade The mouth with the reduced amount of illumination on the teeth makes the strongest demand for lightness of shade.

42. Dentogenic concept (John P Frush , Roland D Fischer JPD 5:587-595, 1955) Dentogenic describes such a denture (or restoration) as is eminently suitable in that , for the wearer , the denture adds to the persons charm, character, dignity or beauty in full expressive smile. Dentogenic means the art, practice and technique used to achieve the esthetic goal in dentistry

43. SPA- Factor ( John P Frush , Roland D Fischer JPD 6:161-172, 1956 ) INTERPRETATION OF SEX Expression of feminine characters - • Roundness, smoothness and softness that is typical of women. The feeling of softness is typical of feminine form. • Select a mold which expresses softer anatomic characteristics or one which is highly adaptable to being shaped and formed into a delicate type of tooth by certain recommended grinding procedures.   Curve suggest softness

44. The selection of a basic shape which has the soft lines expressive of the feminine form, together with effective personality characteristics is particularly helpful. Thus selection of a basic feminine tooth form is conditioned by the personality and age factor . Softer type interpretation of feminity

45. Expression of masculine characters A schema of masculine form illustrates cuboidal, hard, muscular, vigorous appearance which is typical of men. • Masculinity expresses aggressiveness boldness, hardness, strength, action and forcefulness. • But some men have a qualifying softness which will guide to compromise the typical hardness of a masculine tooth interpretation.   Tooth form helps in determining the Degree of masculinity, less vigorous mold

46. The Central Incisor - The two positions of the central incisors, set in perfect symmetry, are the starting positions for conventional tooth setups. By bringing the incisal edge of one central incisor anteriorly , we create a position which is evident but harsh . However , if we move one of the central incisors from the starting position out at the cervical end, leaving the incisal edges together we have created a harmonious lively position . The more vigorous position is to move one central incisor bodily anterior to the other.

47. The Lateral Incisors The lateral incisors, being generally narrower and shorter than the central incisors, are less apparent; however, they can impart a quality of softness or hardness to the arrangement by their positions. The lateral incisor rotated to show its mesial surface whether slightly overlapping the central incisor or not, gives softness or youthful ness to the smile.  Positioning of lateral incisor imparts a quality of feminine softness

48. By doing the reverse, that is, by rotating the lateral incisors mesial, the effect of the smile is hardened. We would select the soft positions for the very feminine smile, and the hard positions for the vigorous. It is important to note that nature never repeats herself, and in the mouth, we avoid symmetry of tooth positions on both sides of the mouth A hardened smile for the vigorous male can be achieved by rotating the lateral incisor mesially

49. The Cuspid Teeth The cuspids should never be set with the tip of the tooth out labially further than the cervical end , except in very rare instances where ,we have to harmonize the arrangement with a rough or primitive type of patient . A prominent cuspid eminence gives to the cuspids greater importance and therefore gives to the smile a vigorous appearance more suitable to the masculine sex.

50. General, we will adopt for the cuspid conjointly the three following positions: out at the cervical end, as seen from the front rotated to show the mesial face almost vertical as seen from the side

51. INTERPRETATION OF PERSONALITY FACTOR Development of personality spectrum is helped in classifying different personalities of patient. This personality spectrum depends upon the individual dentist’s ability to visualize the position of his patients within this framework. Most men are found to be toward the vigorous end of the spectrum and most women are found to be in delicate end of the spectrum.

52. There are three divisions of personality spectrum : • Delicate - meaning fragile, frail, the opposite of robust. • Medium pleasing- meaning normal, moderately robust, healthy and of intelligent appearance. • Vigorous - meaning opposite of delicate; hard and aggressive in appearance, muscular type.

53. When we incorporate the personality factor in esthetics we do so keeping in mind the influence of the sex and age factors as we proceed. • The introduction of different aspects of the personality into dental elements to permit a more precise characterization of the dental composition gave origin to SPA concept of Frush and Fisher.

54. Characterization of anterior segment Frush and Fisher Sex, Age and Personality (SAP) 

55. INTERPRETATION OF AGE • Symbols of youth in the natural teeth are lightness of shade, the unblemished form of the newly erupted teeth, earliest appearance of the mamellon is present at the incisal edge of the central and lateral incisors. • The cuspid presents a pointed tip which is very sharp in appearance. The mamellon is soon abraded away, and the tooth assumes the youthful adult form evidenced by the enamel i ncisal edge of variable depth and of bluish hue. 

56.  Later the sharp tip of the cuspid wears down to a more mature form. As we advance along the chronologic life line of the individual, normal wear, trauma , and, in some instances, malocclusion, and disease make inroads upon the original purity of tooth form. The tooth ages with the individual, and, very often, the mouth condition gets far ahead of the chronologic life line.

57.  In the artificial tooth, then, we may reflect the appropriate age effects by such means as grinding the incisal edges and removing the incisal enamel at such an inclination and to such depth as to convey reality to composition. The sharp tip of the cuspid suggests youth, and, as age increases, it should be judiciously shaped, not abruptly horizontally flattened, but artistically ground so as to imply abrasion against opposing teeth. 

58. Dynesthetic interpretation of the dentogenic concept To construct the dentogenic restoration effectively is a matter of learning and of interpreting the sex, personality, and age of the patient properly in the complete denture . There are three important parts of the complete denture prosthesis. – The tooth – Tooth position – The matrix. If we can treat the tooth, its position, and its matrix correctly, the pleasing personality, masculinity and femininity and the age of the patient, are effectively created. By the application of dynesthetic techniques to the dentogenic concept has considered ease to accomplish this.

59. Dynesthetic theory Patient’s sex, personality, and age are considered as primary factors. Where as dynesthetic techniques are considered as secondary factors of dentogenic restorations. For e.g. , artificial teeth are selected according to the personality of the patient, subsequent sculpturing is directed toward accentuating masculinity or femininity, and the denture base color and contour helps to satisfy the age factor. These secondary factors are called dynesthetics . Dynesthetics means vital beauty.

60. Prefix dyn taken from greek word dynamis , meaning power . Means producing effect of movement or progression. As we know edentulous mouth is in constant and permanent change, our efforts should be in fabricating prosthesis which follows the physiologic age changes in the tissues. 

61. Dynesthetic techniques. It concerns with three important divisions of denture fabrication. The tooth, its position, and its matrix. Techniques includes Mold selection Depth grinding Abrasion Identification of masculinity or femininity  Smiling line specific positioning and rotation of anterior teeth Embrasures and diastemas Buccal corridor Long axes of the teeth Gum line denture base contouring and tissue stippling

62. Dynesthetic considerations to the production of a Dentogenic restoration . Progressive abrasion of the artificial tooth is done as the age of the patient progresses. Depth perception is limited in the artificial tooth because the contact point is too near the labial surface. The perception is increased by depth grinding. This is a cut made on the labial mesial line angle of the artificial tooth. In personality mold selection, a delicate mold is feminine, vigorous mold is masculine and medium pleasing personality mold for both.

63. THE THIRD DIMENSION-DEPTH GRINDING The " denture look " is due mostly to the flat appearance of the artificial upper anterior teeth , their lack of depth, or of "body." The depth grinding is done on the mesial surface of the central incisor only. Central incisors are the widest, almost always the longest, and therefore, the most noticeable of the six anterior teeth. It is necessary to develop the desired effect in the depth grinding by consideration of these main factors.

64.  A flat thin narrow tooth is delicate looking and fits delicate women ( little depth grinding) A thick bony big sized tooth heavily carved on it’s labial surface is vigorous and to be used exclusively for men ( severe depth grinding) For the average patient the depth grinding will be an average between delicate and vigorous Depth grinding reduces the width of the central incisor according to the severity of grinding to be accomplished. 

65. LIP SUPPORT It is the bodily antero -posterior position of the teeth which adequately supports the upper lip in a natural manner. Pleasing lip support is achieved by the anterior teeth and their matrix. 

66. MIDLINE The features of a face usually slant one way or another. It is difficult to see a true midline in dentition. Hence eccentric midline in a denture, if not too exaggerated is acceptable.

67. LABIOVERSION Labioversion is necessary because the most pleasing effect is obtained when the long axes of the central incisors are either vertical or with a slight labial inclination. SPEAKING LINE The speaking line is the incisal length for the vertical composition of the anterior teeth. It is spoken of as the speaking line because the final evaluation of the incisal length is made when the patient is speaking. a) Young women - 3mm below lip at rest b ) Young men - 2mm below lip at rest c ) Middle age -11/2 below lip at rest d ) Old age - 0mm to 2mm above lip at rest

68. SMILING LINE The smiling line is a curve whose path follows the incisal edges of the central incisors, lateral incisors and to the tips of the cuspids . Its arc is determined by the age of the patient and decreases as the patient gets older. The sharp curve of smiling line is youthful . The broader curve of smiling line indicates an older dental composition.

69. SPECIFIC POSITIONING AND ROTATION OF ANTERIOR TEETH The high level of incisal edge of lateral incisor to the central incisor is indication of older dental composition. Incisal edge of lateral incisor in level with the central incisor is indication of youth. Central incisor position: Their placement control’s 1-midline 2-speaking line 3-lip support 4-labioversion 5-smiling line composition Lateral incisor position: Its rotation will either harden or soften the dental composition. Cuspid position: It supports the anterior arch form in its widest part and controls the size of buccal corridor

70. SPACES – Spaces placed between the anterior and posterior teeth gives more effect if placed artistically and hygienically. Rules are It should be V-shaped to shed food. Diastema between central incisor is unsightly so should be avoided. It should be asymmetrically placed on either side of the dental arch. Width of the diastema should be minimum.  V shaped areas are the proper self cleansing Form of all diastemas

71. BUCCAL CORRIDOR It is a space created between the buccal surface of the posterior teeth and the corner of the lips when the patient smiles . Buccal corridor begins at the cuspid . Size and shape of it are controlled by position and slant of the cuspid . It masks the “ molar to molar smile”, which is the characteristic of a denture . Buccal corridor in natural dental composition Molar to molar smile

72. INTERDENTAL PAPILLA It forms main part of the tooth matrix (visible denture base) It occupies one-third of the total importance of the dental composition. It creates self cleaning inter dental area. Determines the age interpretations. Determines outline form of the tooth. The shortening of the papillae is noticed as age progresses Interdental surface of the papillae must be convex in all directions to self-cleaning

73. Achieving complete denture esthetics Accurate impressions Jaw relation Selection of anterior teeth Arrangement of teeth Characterisation of denture base

74. Impression stage Role of esthetics is to develop labial and buccal borders so that they are not only retentive but also support the lips and cheeks properly. Care must be taken not to over support these structures with borders that are too thick. Functions of the denture base -Support the artificial teeth & provide retention -restore the form and appearance of lost soft tissues and alveolar bone Denture esthetics is more than tooth selection

75. In maxilla the resorption of bone takes place labially and bucally with reduction in height and width of the alveolar process Little if any resorption takes place in the depth of the sulcus where at the root apices there is little alveolar bone. The denture base by implication be as thin as possible in this region. Thickness can cause unnatural plumping of the upper lip at the base of the nose and give upper lip a convexity. Thickness in the premolar and molar regions region is permissible and can even enhance retention by allowing a more effective lateral seal with the cheeks.

76. Stock trays will not record the labial sulcus correctly Presence of ill fitting tray displaces the lip making sulcus excessively thick Special tray should be as thin as possible in this region To avoid excessive support of the upper lip the labial extension of the impression should approach a knife edge.

77. T he same technique can be applied to taking the lower impression If alveolar process is well developed then the technique is similar to that of upper. Resorption be pronounced , then the lack of definite demarcation between the sulcus and the remainder of the denture space makes the technique difficult to justify.

78. Registration Stage/ Jaw relation Construction of occlusal rims A, dentate B, edentulous maxilla The labial surface of the central Incisor or the registration Block is 8-10 mm in front of Palatine papilla. Normal relationship of natural anterior teeth with proper lip support

79. Registration Stage Resorption pattern of maxillary anterior ridge showing corresponding placement of occlusion rim Resorption pattern of mandibular anterior ridge showing corresponding placement of Occlusion rim

80. During registration stage of complete denture construction, wax is added to or removed from the labial surface of the upper block until a satisfactory degree of lip support is achieved , appropriate to patient’s age. Tooth visibility is also adjusted , by adjusting the height of the wax block. At first tryin the pt felt that inadequate support was being given to the upper lip Upper teeth were moved forwards but the appearance was unacceptable because more tooth was now visible o n smiling

81. Anterior teeth selection T here are no thumb rule for this procedure however there are anatomic landmarks that can be used as guides . Shade selection: Its based on patients hair and eye color skin complexion and age It has been recommended to select 1 ) Darker shade for older 2) Darker shades for men with vigorous and bold personality 3) Lighter shade for women patients with delicate personality 4) Lighter shade may be selected for central incisor than for canine 5) For young patients anterior teeth should be selected with blue/gray incisal edge or translucent incisal edge.

82. Observation of shade guide: Outside the mouth along the side of the nose, helps in establishing basic hue, brialliance and saturation. under the lips with only the incisal edge exposed - this will reveal the color of teeth when the patient mouth is relaxed.

83. o v o i d t a p e r i n g r e c t a n g u l a r s q u a r e Size and mold Patient preextraction records Square , tapering, rectangular, ovoid- the theory of matching teeth to face form( J.leon williams ) Bizygomatic width div by 16 gives estimated width of max CI

84. Improper vertical dimension can have a profound effect on esthetics. The patient looks prognathic and old below the nose with a vertical dimension that is overclose , excellent esthetics when the vertical dimension is properly restored. Overclosure of the vertical dimension of the occlusion. Note the prognathic appearance and decreased lower facial length. Proper vertical dimension of occlusion. Note how much younger the patient appears.

85. Posterior Occlusion as i t r elates to denture e sthetics One area often overlooked or misunderstood is the effect of the posterior tooth position on esthetics . An extremely poor esthetic denture can result by establishing the posterior plane of occlusion too high or too low. This is demonstrated by the patient who smiles, and the maxillary posterior teeth can be seen hanging down below the plane of the maxillary incisors. Posterior occlusal plane lines up from the maxillary incisal edges to a point halfway up the Retromolar pad (Camper’s line).

86. The buccolingual placement of the posterior teeth can also affect esthetics. If the maxillary teeth are placed too far to the buccal aspect, then the buccal corridor between the maxillary posterior teeth and the corner of the mouth is lost. If the maxillary teeth are placed too far lingually or palatally , then they appear not to exist. Buccolingual placement of the posterior occlusal plane . The lingual control line runs from the mesial contact of the cuspid to the lingual aspect of the retromolar pad.

87. Denture base characterisation The esthetic denture bases are indicated for – Patients with an active upper lip, Patients with a prominent premaxillary process, Theatrical performers, singers, and others who may expose normally unobserved gum tissue areas during their performances, and the psychologic effect on the patient. 88

88. Characterization of denture base In the wax up the following characterizations can be done - Rugae - Frenula - stippling - Gingival sulcus - Festooning - denture base staining Denture base carved and tinted to appear natural . Correct anatomy of the palate with cingulum carved on anterior teeth and lingual surfaces carved on the posterior teeth. The palate is also tinted.

89. Anatomic wax-up . Anatomic wax-up . Anatomic wax-up. Note that the palate is lightly stippled so as not to appear shiny.

90. Denture base characterization Adapt wax and contour it above the necks of anterior teeth to give a gingival bulge, simulating attached gingiva Contour the canine eminence Slight root prominence of central incisors Carve the gingival papillae –convex Stippling can be done with modified bristle brush or tooth brush- in attached gingival area(confine to interproximal areas) 91

91. Denture base characterization Tinting of denture base is done Cases are tinted in four basic shades: light complexion blue-eyed blonds, medium complexion brunettes, dark-complexion brunettes, and non-Caucasians. Fibres and pigments are added to the acrylic resins for a more esthetic appeal 92

92. Tinting and staining of dentures Steps in tinting Described by Rudd and Morrow 5 primary tinting resins: H- light pink (basic colour) attached gingiva F- light red A- medium red (use cautiously) E- purple (used sparingly in most dentures) B- brown (in heavy gingival pigmentation) 93

93. Denture base characterization Steps in tinting 94 Tints are sifted around teeth. The palate is tinted.

94. A New System for Choosing the Form and Size of Complete Denture Anterior Teeth Dario Melilli, Fabio Calandra1, Pietro Messina, Giuseppe A. Scardina The technique consists of a system that allows the dentist to choose and, if necessary, easily change the dental mold during maxillomandibular recording session. The unique feature of the system is that six teeth of each mold are represented by veneers, which are connected to each other on the lingual surface by a fiber that allows each veneer some degree of movement. This technique allows the three-dimensional verification of the patient’s esthetics and realistic phonetic test during the session of maxillomandibular records; if necessary, the dentist may easily replace the mold with a different one in form or size, without working the wax to move or replace a tooth.

95. 96

96. Customized soft tissue reconstruction using SR Nexco The three-dimensional soft tissue contours should be customized with shade characterizations. In the same way as different shades of wax are used for the try-in, different shades of resin should be used to reproduce the colour variations found in the natural gingiva. The light-curing lab composite SR Nexco ® Paste is ideally suited for this purpose. This material is available in a comprehensive range of Gingiva shades including intensive shade variants. Natural-looking soft-tissue esthetics can be reproduced using a straightforward method . Given its non-sticky consistency, the composite is easy to apply and does not need to be warmed up prior to application. 97

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98. Classification of esthetic errors Inharmonious dentofacial ratio Shade disharmony Compositional incompatibility 1. static denture in dynamic mouth 2.Inharmonious strength or weakness of dental composition compared to background features a. Weak mouth with strong face b. strong mouth with weak face A static denture Cardinal sin against the principle of visual perception

99. Intrinsic dental disharmony Space allocation error 1 Inadequate vertical space allocation 2 excessive vertical space allocation 3 excessive horizontal space allocation Structural line errors 1 elevated occlusal plane 2 occlusal plane drops down posteriorly 3 asymmetrical occlusal plane C Unnatural lines 1 Reverse smiling line 2 unnatural axial inclination 3 cuspless posterior teeth 4 gradation errors 5 Age-Sex-Personality disharmony

100. D Single –line errors 1. Vertical deviation 2. Horizontal deviation 3. Line conflict E Imbalance 1. Midline errors 2.Imbalance of direction 3. Artifact error 4. Diastema error Use of short posterior teeth destroys the illusion Of gradual reduction in the size, sin against the Principle of gradation Raising or lowering of one adjacent line destroys the illusion

101. Summery:- For a complete denture prosthesis to be successful it should be mechanically sound , physiologically acceptable and esthetically pleasing . By having a knowledge about principles and fundamentals of esthetics and by following simple steps to incorporate this knowledge in complete dentures more life like restorations can be fabricated.

102. References:- Zarb,Bolender , Prosthodontic treatment for edentulous patients.Twelfth edition Sheldon Winkler , Essentials of complete denture prosthodontics,second , edition 2000 Richard E. Lambarde : The Principle of visual perception and clinical application to denture esthetics , Journal of Prosthetic Dentistry . 29:359-381 ,1973. John P. Frush , Ronald D Fisher :Introduction to Dentogenic Restorations , Journal of Prosthetic Dentistry ,5:587-595,1955. John P. Frush , Ronald D Fisher :The Dynesthetic interpretation of Dentogenic concept, Journal of Prosthetic Dentistry. 8:559-581, 1958. D J Lamb: Appearance and Aesthetics in denture practice, wright bristel , 1987.

103. THANK YOU!!