Dynesthetic and Dentogenic Concept Revisited WILLIAM 5. JAMESON, BS, DDS* ABSTRACT ‘The dynesthetic and dentogenic concept, when applied, provides a more natural, harmonious prosthesis, which not only is desired by patients, but also is a quality of care they deserve. Outstanding esthetics can be achieved by simple guidelines, using tooth molds specifically sculpted for males and females, arranging prosthetic teeth to correspond with personality and age and sculpting the matrix (visible denture base) with more natural contours. There is no reason for edentulous individuals to be provided with care of any less quality than that avail- able with other procedures, such as crowns, bridges, veneers, or implant restorations. Provid- ing this upscale product can be rewarding and satisfying to patient and operator alike, This concept produces superior results no matter what posterior occlusal scheme is employed but, in the opinion of the author, works best when used in conjunction with a noninterceptive linear occlusion approach (not to be confused with lingualized occlusion), which precludes anterior contact. (CLINICAL SIGNIFICANCE Dentogenics provides an approach to esthetics in prosthodontics that enables the dentist to create 4 restoration in harmony with the patient’s objective personality. This concept considers gender, age, and personality to restore the patient’s dignity and unique individuality that has been miss- ing in far too many prostheses. here exists a natural desire on the part of edentulous individ- uals to avoid an appearance of aging or “the denture look” associ- ated with old age. Current society is obsessed with the need to appear youthful, to avoid any appearance of inevitable aging," Unfortunately, as pointed out by Donovan and col- leagues,? it is their opinion that the majority of complete dentures fab- ricated do not achieve the esthetic potential currently possible. This is an esthetic ned that is not being, met by the profession. “Consultant, Department of Veterans Affairs, Tucson, Aczona () Esthet Restor Dent 14:139-149, 2002) ‘A new approach to esthetic con- cepts, known as the dynesthetic concept, was suggested by Frush and Fisher over 40 years ago when they authored a series of articles that presented a concept of esthet- ics based on gender, personality, and age.-* To achieve a more natural-appearing denture, three ingredients were necessary: the right teeth, placed in the proper position, and held in place by a natural-appearing matrix (visible denture base). ‘Traditionally, most dentists were taught to arrange anterior teeth on a “silver dollar” curve with their incisal edges straight across and ong axes radiating from a common point of origin. This was done with ‘molds that could be used for both ‘males and females (Figure 1). A perceived need to place anterior teeth over the crest of the residual ridge for mechanical stability thus produced a truly “false teeth” look. Besides crowding the tongue, this approach made it necessary to use VOLUME 14, NUMBER 3, 2002 139140 DYNESTHETIC AND DENTOCENIG CONCEPT REVISITED Figure 1. A thin upper lip with all incisal edges straight and even, typical of “false teeth” dentures. smaller teeth to fit within the space Frush and Fisher advocated use of available, which resulted in lack of appropriate molds for males and normal upper ip support. Introduc- females rather than attempting to tion of the influence of gender, per- make a single mold work for both. sonality, and age on arranging ante- To simplify this decision-making rior denture teeth was revolutionary process, a pictorial guide (Mold in light of what was being practiced Selection Guide, Geneva Dental, by the profession. Inc., Beverly Hills, California) of these three personality categories Ina dentogenic restoration, embody- of men and women, as well as a ing gender, personality, and age, _ suggested mold for each category, gender and physiologic age are is available (Figure 2). These six readily determinable, But personal- molds, in shades appropriate for ity, the most difficult to determine, is the best measure of each patients priceless individuality. It is the objective physical personality that is unique for each individual. In the course of normal social activity, the smile is the primary objective per- sonality of a human being. ‘An individual falls into one of three categories: delicate, moderate, or vigorous. By selecting a mold cate- gory of artificial teeth that corre- sponds with a patient’s objective personality, itis possible to restore harmony between the personality of artificial teeth and the personality of an individual, compatible tooth molds JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY the patient's skin tone, satisfy the needs of the vast majority of patients, Rather than attempting to select an appropriate mold from all those available, its use not only speeds the process but also ensures a greater margin of accuracy for dentists with limited experience, Frush and Fisher also advocated rotational and positional variance with individual anterior teeth to achieve different light deflections, enhancing the appearance of vital- ity in nonvital substances. This produces natural asymmetry, as seen in nature. Positioning of lat- eral incisors either softens or pro- duces ruggedness depending on the patient's gender. Canines are arranged with their long axis posi- tioned vertically. The neck is more prominent than the incisal edge for women, and from the front, Figure 2. Three male and female personality types with their‘only the mesial half is visible, This is consistent with the divine or ‘golden proportion concept,?-!? which, although not a scientifically valid concept,"? has been proven to be an excellent artistic approach upon which to build, From a frontal view, central incisors are longer than lateral inci canines slightly higher than later- als, creating a curve of the incisal edges that follows that of the lower lip when the individual smiles (Figure 3). This became known as the “smile line.” rs and Using noninterceptive linear oeclu- sion posterior teeth (Auto-Centric Posteriors, Geneva Dental, Inc.) and the bilateral falcrum of protru- sive stability," maxillary anterior teeth are positioned where they were prior to loss, anterior to the ridge crest. ‘Thus, functional ante- rior rotational contacts are avoided (Figure 4). This promotes stability and positioning that enhances both phonetics and esthetics. Previously published articles regarding esthetics have concen- trated on the maxillary anterior six and achieving a pleasing smile line, Little attention was given to arrangement of the mandibular anterior teeth. Irregularity in the arrangement of these teeth results in staggered, uneven incisal edges, similar to a metropolitan sky line. Thus, the too perfect monot- ‘ony of straight, even incisal edges is avoided. Creation of a natural- JAMESON Figure 3. Typical dentogenic female arrangement and smile line following curvature of lower lip. appearing mandibular “sky line” in reality is actually as important as the smile line, since an individual talks considerably more than he or she smiles. It is natural for ‘mandibular anterior teeth to show during speech, while the upper lip, which is relatively inactive, hides the maxillary teeth. Arrangements in either arch that are too perfect tend to be monotonous and appear false, lacking in asymmetry that creates an illusion of naturalness.! ‘When presented and explained prior to treatment, this approach is readily accepted by patients, With linear occlusion, mandibular anterior teeth, which are intended more for esthetics than funetion, can be placed with their labial surface falling within the labial vestibule. Long axes can be varied (Figure 5), as well as their position labiolingually (Figure 6), creating irregularities and asymmetry. Since this occlusal concept avoids ante- rior contact, any horizontal overlap Figure 4. ‘The bilateral fulcrum of protrusive stability. Only the blade of the lower second premolar contacts the upper tional contact. firs premolar occlusal surface edge, preventing anterior rota VOLUME 14, NUMBER 3, 2002 141ma DYNESTHETIC AND DENTOGENIC CONC! and absence of vertical overlap become nonfactors, Stability of the mandibular prosthesis is greatly improved, and trauma, which causes most resorption of anterior residual ridges, is eliminated or reduced. With no actual anterior contact, use of porcelain anterior teeth, which possess greater translu- cency and luster than their acrylic resin counterparts, is not only pos- sible but recommended. The other ingredient is the matrix (isible denture base). When using teeth with longer proximal contact areas (Geneva 2000 Porcelain Ante- riors, Geneva Dental, Inc., itis pos- sible to produce teardrop contoured interdental papillae (Figure 7). This sheds food particles more efficiently than high, sharp, depressed inter- proximal spaces. Deep festooning or depressions accentuating root prominences should be avoided. Smoother, more subtle depressions and convex contours between tooth Figure 5. Typical linear occlusion maxillary and mandibular trial denture. Dentogenic irregularities of upper anteriors are ‘mimicked in lower arserions neck and peripheral border are actually more conducive to restor- ing lost tissue contour on the pol- ished surface of the denture, Stip- pling helps break up light reflection as well as prevent food adherence, but should never be done in areas of attached gingivae near the necks of teeth, Mimicking nature always works best; therefore, detailed casts ‘of dentate mouths produced from accurate, irreversible hydrocolloid impressions are an excellent source for guidance in contouring.' Also, half-moon gingival contouring at the necks of teeth is unnatural and should be eliminated. As with nat- ural dentition, contour of the gingi- val crevice is determined by root prominence. The more prominent the area, the more root exposure created (Figure 8). Even though spaces beneath contact areas may be present in periodontally involved natural dentition, this should not be duplicated. Unsightly or unattrac- acteristics should never be JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY duplicated no matter how natural they might appear, It might look totally in harmony with an individ- ual’s personality and age but be dif- ficult to keep clean and produce undesirable food traps. Since technicians must arrange anterior teeth on a wax occlusal rim without benefit of sceing the patient,” accurate communication between dentist and technician is essential in complete denture prosthodontics. The bridge between laboratory technician and patient is the wax occlusal rim. It is critical that this communication vehicle possess those qualities that effec- tively transmit the desired informa- tion. There are many types of wax ‘occlusal rims, but the one preferred by the author is the esthetic control base (ECB) used with linear occlu- sion.'* It is fabricated using alameter and papillameter (Geneva Dental, Inc.) measurements derived from the patient. When critiqued at the Figure 6. Incisal view of mandibular arrangement. Irreguley- ties and asymmetry contribute to natural appearance.INMESON Figure 7. Maxillary and mandibular prostheses inomediately Figure 8, Natural denition exhibiting gingival contouring following cementation of lower porcelin-fused-to-meral influenced by root prominences. Note the gingival crevice of restorations. Maxillary complete denture with the tybe of both maxillary central incisors inclines uptoard from the mesial {gingival mati recommended in dentogenics (i.e. rownded, toward the distal root prominence ofthese rotated teth feardrop snterdental papillae). relation record appointment, the sibility of the dentist to become accomplished by a dentist, person- anterior portion is verified to be knowledgeable regarding how and ally, rather than a technician they parallel to the desired horizontal where to arrange at least these two never see and who never sees them. ‘occlusal plane and even with the teeth, preferably during the relation upper lip at rest. Midline and high record appointment. Normally, for Creating an esthetically pleasing lip line are marked after determin- females, the labial surfaces of these composition does not necessarily ing proper lip support to be present two teeth are located approxi- depend entirely on one's artistic in both a frontal and profile view. mately 7 mm from the middle of ability. Creating a one-of-a-kind Itis also possible to verify presence the incisive papilla 2° Males have a masterpiece with each setup is of a proper buccal corridor lateral thinner, more muscular upper lip! not necessary. Following simple to canine markings on either side Placement of their central incisors guidelines for arranging male and (Figure 9). Given this information at a position S mm from the middle _ female molds, selected according and the patient's age, either opera- of the incisive papilla is an excellent to personality, results in outstand- tor or technician can arrange the _starting point in achieving desired _ing esthetics. maxillary anterior teeth. With lin- lip support. This difference results ear occlusion, maxillary central _in males showing less ofthe incisal Principles of arranging artificial incisors are key elements in estab-_ portion at rest than females, prosthetic teeth in removable lishing the horizontal occlusal which is normal. Ic is far less time- _prosthodonties are applicable to plane. Their proper positioning is consuming and more cost efficient __fixed prosthodontics as well (Figure ‘essential, not only for esthetics and for dentists to properly accomplish 10). Unless the arrangement is made phonetics but also in determining this procedure than having to have asymmetric, the resulting compo: the proper posterior occlusal plane. a reset and retry of the trial denture tion of multiple porcelain-bonded- one or more times. Experience has to-metal restorations takes on a flat, No matter what posterior occlusal demonstrated that nothing builds solid, artificial appearance. Even concept is used, proper positioning more value into the service being _exceptional talents of highly skilled ‘of maxillary central incisors is para~_ provided than for patients to sce technicians in blending and shading mount. Therefore, it is the respon- this particular procedure being. are overshadowed by such a monot- VOLUME 14, NUMBER 3, 2002 143DYNESTHETIC AND DENTOGENIG CONCEPT REVISHTED Figure 9. Fsthetic control base exbibiting buccal corridors parallel to horizon, nous arrangement. Skillfal lapping, rotation, and long axis angulation modifi erally come alive. tion make restorations lit- ‘The purpose of this article is to pro- vide a procedural guide for arrang- ing maxillary anterior prosthetic teeth. By following this guide, a pleasing, natural-appearing arrange- ment of teeth, in harmony with and satisfying the unique esthetic needs of each individual, is rou- tinely achieved. This makes it possi- ble to satisfy a need in a segment Figure 10. A, Maxillary fixed restorations exhibiting female ddentogenic characteristics. B, Anterior restorations exbibit characteristics that are in harmony with patients objective personality. and midline marking with expansive smile; anterior portion ‘of the population that has been treated inadequately in the past. TECHNIQUE ‘When arranging maxillary anterior teeth, positioning of central incisors is paramount. They are not only the dominant actors on the stage of expression, the smile, but are also crucial in determining the plane of occlusion for function. The desired lip support and position are verified during the ECB critique. Incisal edges should be straight and labial surfaces vertical (Figure 11), with one central JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY slightly in front of the other. This holds true for both males and females. Using the ECB length as a ‘guide, which is even with the upper lip at rest, central incisors are arrang.- ed according to patient’s age and ‘gender. Normally, for mature males, the incisal edge is even with the lip at rest. A middle-age man would have ‘1 mm of tooth visible below the lip at rest. For females, age also deter- ‘mines how much tooth is visible: more for younger women (2-3 mm) than for more mature women, but at least I mm regardless of age. ‘The wax is softened and prepared for one central incisor to the midline mark, Ie is desicable to have the neck of the tooth positioned at the high lip line to minimize show of base ‘material when the lip is raised to its ‘maximum extent. The first central is positioned so that its mesial surface is contacting the wax, and the pins are sealed to place (Figure 12). UsingFigure 11 Stone cast showing normal Aeron croumeroct angudation. Used argue rain prose replace ‘nent eth tis esas in postions ante Nort be eden resiua ge, teeth that have a broad contact area, such as found in the Geneva molds, is preferable, When the wax has chilled so the tooth is firm, wax in the adjacent central incisor area is prepared and that tooth arranged using the previously positioned tooth as a guide for length, but either in Figure 12. Wax sufficient 10 accommodate the maxillary left central incisor has been removed and the replacement tooth positioned contacting the wax midline. The position of the incisal edge above the wax rin is consistent for the patient, who is a mature female. front of or behind the other central, and then luted to place (Figure 13). Once this wax has chilled, the ECB with the two central incisors is placed in the patient’s mouth. The amount of tooth visible, ip support, ‘maximum lip elevation (to check position of the necks), and midline (location and angulation) are veri- fied as correct prior to proceeding. If modification is necessary to achieve any of the established goals, it is done before proceeding Frequently, in anterior hyperfunc- tion syndrome, there is extensive loss of the maxillary residual ridge (Figure 14), This makes it difficult to determine where the incisive papilla was and, therefore, the labial extent of the wax rim, During the critiquing process, if it becomes evident that major changes are necessary, it is more time-efficient for the operator to position the central incisors to achieve the desired lip support and tooth visibility than to modify the wax rim and then arrange the JAMESON teeth, Moving central incisors labially produces more lip support and raises the lip, necessitating moving them up as well (Figure 15). How much is needed is best determined by the operator while arranging these two teeth, before proceeding, rather than by written instruction to the technician, If the operator elects to arrange the remaining maxillary anterior teeth, lateral incisors are positioned fol- nes. Otherwise, the lowed by ca ECB with its ewo central inci and the relation record are sent to the laboratory for the technician to «establish the horizontal plane of ‘occlusion after mounting the casts in an articulator. Arrangement of the remaining anterior prosthetic teeth, maxillary and mandibular, is then accomplished. These can be returned to the operator for verif cation of correctness prior to com- pletion of the setup or the posterior teeth can be arranged and the com- pleted trial denture returned for evaluation and verification, Figure 13. The right central incisor has bbeen positioned using the left central incisor asthe determining guide. VOLUME 14, NUMBER 3, 2002, 145146 DYNESt Figure 14. A, Extensive loss of malay residual ridge males determining where to Position replacement pros thetic teth difficult, Proper postion must be verified tet a wos ocelesal rn such as ECB. B, Example of Incorrect positioning of max illary anterior replacement teeth, Patient has advanced manifestations of combina tion syndrome. If the denture laboratory is in another city, itis difficult for the laboratory and doctor to send an articulator back and forth through the mail. A solution would be to first mount the casts in the doctor’ office Prior to mounting, a separating ‘medium is applied to the base of cach cast after it has been indexed to facilitate removal and remount ing, Relation record and casts are then removed from their mounting and forwarded to the laboratory to be mounted anew on another artie- ulator. There is a definite advantage in using an intraoral tracing luted together with quick-setting stone or impression plaster. When the trial denture is returned for verification, the doctor is able to remount the TE AND DENTOGENIC CONCEPT REVISITED casts on the original articulator for evaluation prior to proceeding. With either approach, lateral incisors are positioned after the cen- tral incisors (Figure 16). Their posi- tion is dictated by patient gender and amount of vigor desired in the arrangement. Any personality cate~ gory can be made softer or bolder by increasing or decreasing their position and rotation. First one side is prepared to receive the tooth and then the opposite lateral incisor is positioned. Pins are secured in wax, and after the wax has chilled, canines are positioned (Figure 17). Once the canines are arranged in turn and sealed to place, the setup is placed in the mouth for evaluation. Its advisable not to permit patient viewing at this stage, Lack of teeth in the posterior changes the patient's perception, just as viewing teeth on a tooth card is difficul for a patient to appreciate. The patient's eyes are accustomed to seeing a completed denture with all teeth present, good or bad, and the dentogenic arrange- ‘ment is markedly different. Although patients want to look bet- ter, they fear looking different and will need to be conditioned for the change. The operator is better quali- fied to determine if the arrangement produces the desired harmony with the patient’s personality Itis also not advisable to allow the patient to view the arrangement with a hand Figure 15. A, To achiove the desired lip support, the maxillary central incisors have been positioned anteriorly or labial. B, Incisal edges of vhe maxillary central incisors are parallel to the anterior portion of the ECB, but below it, for the desired lip ‘support. C, Lip support and tooth visibility are evaluated before proceeding with remainder of anterior arranigement, JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRYJAMESON Figure 16. A, Maxillary lateral incisors arranged with asymmetry depicting sofimess consistent with female characteristics. B, Incisal view revealing prominence of mesiofacal line angles of maxillary lateral incisors. mirror at any time. Viewing froma allowed to view the proposed ‘waxing completes the dentogenic speaking distance, when the trial restoration (Figure 18). restoration, giving dignity and indi- denture is ready, provides for proper viduality back to the patient. perspective and allows the patient 0 Character grinding or “aging” the view the denture as others will. teeth creates the illusion necessary CONCLUSION ‘Only when the completed trial den- to harmonize with the patient's per- For too long, edentulous individu- ture is ready should the patient be sonality and age. Skillful matrix als have accepted a false paragon Figure 17. A, Canines arranged with female characterstics—neck more prominent than incisal tip. B, Canines positioned 10 reveal mesial half of labial surface only. Figure 18. A, Completed arrangement of maxillary trial denture exhibiting male dentogenic characteris- tics. This is a'reverse articulation situation with linear occlusion blades arranged in maxillary arch. 1 Completed arrangement of maxillary trial denture exbibiting female dentogenic characteristics. VOLUME 14, NUMBER 3, 2002 147us DYNESTHETIC AND DENTOGENIC C1 Figure 19. A, Patient with a complete denture she bas wor for 30 years conveying that gave them a “false teeth” look. They erroneously assume that this denture look is an unavoidable consequence of losing their teeth. Every patient cannot afford the expense of full-mouth or implant reconstruction in an effort to avoid complete dentures. Should they become edentulous, by employing dentogenic principles and concepts, it is possible to restore their dignity and individu- ality. Self-confidence and a vibrancy for life are rekindled. ‘This procedure makes possible an exceptional service that has been missing from the practice of prosthodontics (Figure 19). ACKNOWLEDGMENTS ‘The author has no financial inter- est in any of the companies or products mentioned in this article. definite "false teeth” look. B, Same patient with new prosthesis, which is more in harmony with her gender, personality, and age. REFERENCES 1 Keajcek DD. Dental atin prosthodontic. ‘Pronthet Den 196852122131, Donovan TE, Desbabian K, Kaneko L, ‘Wright R Esha consideration ia removable prosthodonticsJ Esthet Rexor Dent 20015 15:241-253, rush JP, Fisher RD. ltrodution vo den- togenicrexorations J Pronhet Dent 1958: 886595 rush JP, Fisher RD. How dentogeie restorations interpret the sex factor. Prosthet Dent 1956; 6160-172 Frush JP, Fisher RD. 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