Anterior Dental Aesthetics

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IN BRIEF
• Aesthetics is neither an art nor a science, but a fusion of the two.
• Ancient Greeks postulated basic concepts in an endeavour to quantify beauty, including the
Divine Proportion, symmetry, unity and harmony.
• The Gestalt Principle is a psychological theory, which can be used for unifying aesthetics in a
logical manner.
VERIFIABLE
CPD PAPER
Anterior dental aesthetics: Historical perspective

I. Ahmad1
The purpose of this series is to convey the principles governing our aesthetic senses. Usually meaning visual perception,
aesthetics is not merely limited to the ocular apparatus. The concept of aesthetics encompasses both the time — arts such as
music, theatre, literature and film, as well as space — arts such as paintings, sculpture and architecture.
INTRODUCTION interdependent and interrelated. However, for

ANTERIOR DENTAL The first point of contention regarding aesthetics the sake of discussion, this series compartmen-
AESTHETICS
is its definition. Is it an art or a science? Science talises dental aesthetics into compositions or
1. Historical perspective has long propagated allusions to objective criti- perspectives, according to the viewing distance.
2. Facial perspective cal analysis, which are now unfounded and Starting with the facial perspective, and zoom-
3. Dento-facial perspective vehemently refuted. In reality, any scientific ing closer to the dento-facial, dental and gingi-
4. Dental perspective investigation is tainted by individual, philosoph- val (Figs 1 to 4). Finally, the last part, on the
5. Gingival perspective ical and cultural biases. Art, on the other hand, ‘psychological perspective’, proposes a psycho-
6. Psychological perspective* has been always been portrayed as subjective, logical link between cerebral perception and the
* Part 6 available in the BDJ Book
romantic and empathetic. Whilst fundamental dentition.
aesthetic principles are based on Greek and Before embarking on individual dental
Roman mathematics, nevertheless, artists con- perspectives, it is necessary to define funda-
ceived aesthetics for creating pleasing paintings mental guidelines, which contribute to aesthetic
that touched our inner souls. One can undoubt- appraisal.
edly decipher the dichotomy of aesthetics,
attracting endless debate by both scientific and COLOUR, FORM AND LINES
artistic communities. Put succinctly, science asks The link between colour and form can be traced
‘how?’, while art asks ‘why?’ to the Greek and Egyptian empires. In fact, much
It is difficult segregating dental aesthetics of Renaissance and Medieval thinking has been
into distinct units, since all variables are plagiarised from the ancient Greek era. For a
1BDS, The Ridgeway Dental Surgery, 173

The Ridgeway, North Harrow, Middlesex,
HA2 7DF, United Kingdom.
Tel: +44 (0)20 8861 3535, Fax: +44 (0)20
8861 6181, www.IrfanAhmadTRDS.co.uk
Email: iahmadbds@aol.com
Refereed Paper
© British Dental Journal 2005; 198:
737–742 Fig. 1 Facial perspective Fig. 2 Dento-facial perspective
BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005 737

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Fig. 3 Dental perspective
Fig. 5 Basic shape: Triangle
Fig. 4 Gingival perspective
detailed analysis of the relationship between

form and colour, the writings of the colour theo-
rist Johannes Itten (1888–1967) are invaluable.
For the purpose of dentistry, a few essential prin-
ciples require consideration. Firstly, in any com-
position, colour is the predominant force, taking
precedence over form, angles and lines. The dif-
ficulty assessing the value (brightness compo-
nent) for a shade prescription is because the eyes
are distracted by the colour (hue and chroma
components) of the tooth.
Secondly, any form can be created from the
three basic shapes of a circle, triangle and
square. These geometric shapes were, and are, Fig. 6 Basic shape: Circle
associated with religious, mystical and esoteric
connotations. For example, in ancient times, the
triangle stood for impending danger, a symbol
that is used today for warning signs on roads.
The circle represented celestial spirituality, infer-
ring tranquillity and egalitarianism, while a
square denoted sturdiness, after the solid base of
the Egyptian pyramids. The maxillary anterior
teeth are a fusion of these basic shapes, a topic
that is discussed further in the ‘Dental perspec-
tive’ article (Figs 5 to 7).
A line can be perceived, without actually
been drawn. The oral cavity has ample examples
of these phenomena. Consider the incisal edges
of the maxillary teeth, often referred to as the
incisal plane. It is the curvaceous arrangement
of the teeth that implies a plane, even though
none is actually present. Further examples are
the curves of Wilson and Spee (Fig. 8). The direc-
tion of lines can also create optical illusions. Fig. 7 Basic shape: Square
Prominent vertical lines on the facial surface of
an anterior tooth will infer a longer tooth, while monies on a musical scale are adjusted equally
distinct horizontal lines have the opposite effect, on both sides, the result is a rhythmic and har-
(wide and short tooth length). monious auditory perception. Similarly, repeat-
ed or recurring ratios in the visual arena are
DIVINE PROPORTION viewed as artistic and aesthetically pleasing, e.g.
Proportion in a composition is analogous to har- the repeated width ratios of the maxillary anteri-
monies in music. When proportions of even har- or teeth.
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Fig. 8 Imaginary anterio-posterior line of the incisal

edges/cusps tips representing the curve of Spee
Ancient Greeks were preoccupied with

seeking methods by which beauty could be
quantified and predictably reproduced by arti-
sans and artists. Their goal was to discover If all animals and plants displayed such exact- Fig. 9 Roman statues based on the
arithmetic simplicity, which could signify ness, we would be surrounded by clones. How- Golden Proportion.
beauty and harmony. This led Pythagoras in ever, even if a plant or animal does not display
530 BC, accompanied by his followers, to seek features conforming to such dogmatic dimen-
refuge in Croton in southern Italy. The objec- sions, its beauty is not compromised. What is
tive of this clandestine gathering was to dis- the reason for this apparent disparity? To cre-
cover a mathematical solution for what was ate diversity and individuality, repeated or
perceived as beautiful or ugly. The answer pro- recurring proportions are more significant
posed by the Pythagoreans’ was the Golden than a specific ratio. Consequently, the ratio
Number, represented by the Greek symbol, ∆ for beauty of 0.618 signifies an ideal. Never-
[(∆5-1) ÷ 2]. The reciprocal of ∆ is 0.618 and theless, other ratios, e.g. 0.577 or 0.8 are also
has been termed the Golden or Divine Propor- perceived as aesthetic, with the proviso that
tion. Objects, animate or inanimate, whose there is repetition, or recurrence in a given
features or details conform to this ratio, are composition.
perceived as having innate beauty. It is impor-
tant to distinguish innate or absolute beauty SYMMETRY
from subjective beauty. Absolute beauty Symmetry is defined as static or dynamic. Stat-
implies that if two objects, one conforming to ic symmetry is evidenced by repetition in inan-
the Golden Proportion and the other not in this imate objects such as crystals or contrived
ratio, are presented to a group of individuals, arrangements (Fig. 10). Dynamic (radiating)
99% will affirm that the object with the Golden symmetry refers to repeated proportions in ani-
Proportion is beautiful. The second type is sub- mate, living or vital beings, such as flowers
jective beauty, which is a psychological con- (Fig. 11). This monumental discovery was Fig. 10 Static symmetry represented
cept, colloquially referred to as ‘beauty in the attributed to the American architect Jay Ham- by identical reflections of teeth in
eyes of the beholder’. bidge, and concurrently by the English scientist this contrived arrangement
The affirmation that the Golden Proportion
signifies beauty has been exemplified by its
ubiquitous prevalence in both the plant and
animal kingdoms, e.g. the logarithmic spiral.
The beauty of flowers, or attractiveness of faces,
has been attributed to features, which conform
to a ratio of 0.618. Architects and sculptors in
antiquity exploited the Golden Proportion for
creating buildings, e.g. the Parthenon in
Athens, and statues having eternal appeal (Fig.
9). Numerous artists have also slavishly used the
Golden Proportion to create masterpieces. For
example, Piero della Francesca’s ‘The Baptism
of Christ’ and ‘The Flagellation’ and illustra-
tions by Leonardo da Vinci for Luca Pacioli’s
‘Divina Proportione’, all demonstrate rigid
adherence to this ratio.
The Golden or Divine Proportion is true for
emulating Olympian beauty, but in nature,
such beauty is neither prevalent, nor desirable.

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Fig. 12 Anterior view of teeth in centric occlusion
Fig. 11 Dynamic symmetry of a Sir D’Arcy Thompson in the 1920s. The art deco
sunflower movement of the 1930s, epitomised by the
Chrysler building in New York, is a classic
example where dynamic symmetry has been
extensively used. The significance of dynamic
Fig. 13 With an anterior protrusion of the mandible –
symmetry provided the missing link between the shorter maxillary lateral incisors avoid interferences
nature, buildings, crafts, and works of art dat- with the mandibular canines.
ing back to ancient Greece. Analysis of Greek
architecture and craftwork confirm identical specific proportions and repeating ratios not
repeated ratios and proportions found in the only for aesthetic appeal, but also for proper
natural world. This was affirmation that geom- function during protrusion of the mandible,
etry alone was inadequate for explaining natu- the upper laterals are shorter, thereby avoiding
ral and artistic beauty, and aesthetic elucida- interference with the mandibular canines (Figs
tion was only apparent when combined with 12 and 13). There are two types of visual forces
the principles of dynamic symmetry. requiring consideration. The first are cohesive
forces, which provide unity and harmony, e.g.
UNITY AND HARMONY two parallel objects (Fig. 14) or an encircling
In addition to divine proportion and dynamic frame (lips bordering the anterior teeth). The
symmetry, unity in a composition is achieved opposite are segregative forces, which convey
Fig. 14 Parallel arrangement of by incorporating balancing forces as well as a tension and interest, e.g. objects that bisect
identical tooth sections, emphasising
dominant key element. It is important to each other in a perpendicular arrangement
cohesive or unifying forces of the
composition. Balance is also evident realise that teeth are arranged with tectonic (Fig. 15). Segregative forced are essential for
by the opposing incisal edges spacing. Tectonic refers to an arrangement that avoiding monotony and adding curiosity and
arrangement, creating equilibrium is both functional and aesthetic. For example, variety to a composition.
and visual stability the maxillary anterior teeth are arranged with Balance ensures equilibrium and stability.
This is similar to a weighing scale, with both
sides having equal weight distribution. In a pic-
torial form, the forces should be balanced for
conveying stability and equilibrium (Fig. 16).
Finally, the protagonist or salient point of a pic-
ture should be dominant. This is achieved by
size, position or colour. A larger object, com-
pared to surrounding elements, conveys promi-
nence. In dentistry, two types of dominance are
evident: individual or segmental. Individual
dominance is related to single units, e.g. wide
and prominent maxillary central incisors. Seg-
mental dominance, usually preferred by
patients, is dominance of a group of objects, e.g.
prominence of the maxillary anterior sextant,
often portrayed by the fashion & cosmetic
industries and haute couture magazines. An
item, whose position is central to the optical
axis, is perceived as the centre of attention, and
hence dominates a composition. Colour is

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another method exploited for creating domi-

nance, especially complementary colours of an
object and its background, e.g. blue object with a
yellow background (Fig. 17).
THE GESTALT PRINCIPLE

This theory combines the above principles of
aesthetics in a coherent and logical manner. Dr
Max Wertheimer initiated the Gestalt theory of
psychology in Germany around 1912, and put
succinctly, its definition is “the whole is different
from the sum of its parts”. For example, the teeth,
made of organic and inorganic matter, have a
profound impact on an individual’s personality
and well-being, which is significantly remote
from the substance from which they are con-
structed. In concurrence with the Pragnanz law,
the Gestalt theory implies that the mind organis-
es the outside world so that it can come to terms
with it. This involves creating meaning, stability,
balance and security. These concepts allow the
observer to achieve a better object-background
(figure-ground) relationship by encapsulating
the following four constituents:
• Proximity
• Similarity
• Continuity
• Closure.
Incorporating the above entities in a compo-

sition results in stability and harmony. Also,
applying the above four constituents for an aes-
thetic makeover creates a good Gestalt, enhanc-
ing psychological appraisal. The four con-
stituents of a good Gestalt are discussed below.
Proximity facilitates association, linking,

grouping, learning, and therefore adds interest.
Segregation, on the other hand, implies disasso- if unable to resolve these conflicts [by conjur- Fig. 15 (top) Perpendicular
ciation, complexity, isolation, un-grouping and ing the missing sequence or stages]; it forgets arrangement of teeth, emphasising
segregative forces in a composition
leads to frustration, rejection or boredom. A them to avoid mental tension and frustration.
dental example is teeth arranged adjacent to Closure is highly dependant on the id, if an
Fig. 16 (bottom) The coloured
each other, without diastemae, avoids detach- individual is confident, assertive and self- effusions on either side of the tooth
ment and aloofness. However, a degree of segre- assured (greater coping abilities), they are like- are located at the top right and
gation is essential for mitigating repetitiveness. ly either to dismiss or ‘come to terms’ with an bottom left opposing corners,
incomplete event. Conversely, an anxious, creating balance and equilibrium
Similarity ensures objects have similar form,
colour, position and line angles, e.g. teeth with
similar shade, form and arch alignment.
Continuity ensures progression, e.g. recurring or

repeated ratios from the maxillary incisors to the
canines.
Closure assures cohesiveness, such as a frame or

border, e.g. lips surrounding the teeth (Fig. 18).
Closure is particularly important for our

satisfaction (visual and otherwise) and learn-
ing process. If conclusions are vague, ambigu-
ous or open-ended, the Zeigarnick effect is
prevalent. The latter is when a task or sequence
is incomplete, the short-term memory recall is
superior, but the message is lost after about Fig. 17 Colour dominance – the blue
twenty-four hours. The result is that the mind tooth is of a complementary colour
to the yellow background
is left in a state of confusion, detachment, and

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extremely important for mental stability by

ensuring equilibrium between our conscious
and unconscious states of mind. A dental anal-
ogy is teeth of different shades, irregular form
and erratic positions causing disharmony and
visual dissatisfaction, and therefore prevent-
ing closure.
CONCLUSION
This article has highlighted some aesthetic
principles relevant to clinical practice. In the
rest of the series, these principles will be used
for achieving a pleasing outcome for aesthetic
dental treatment. The next part, ‘Facial Per-
spective’ discuses ideal facial features as well
as analsing other factors relevant to this
perspective.
1. Hegel G W F. Philosophy of History. New York: Collier, 1905.

2. Lombardi R. Visual perception and denture esthetics.
J Prosthet Dent, 1973; 29: 352–382.
timid and ambivalent personality (low coping 3. Plato. Republic. c 400 BC
4. Ehrenzweig A. The Hidden Order of Art. Berkley: University of
abilities), is unlikely to resolve the predica- California Press, 1971
Fig. 18 A good Gestalt:
Proximity of teeth ment, resulting in consternation. To compli- 5. Ahmad I. Digital and Conventional Photography: A Practical
Similarity of tooth colour and form cate matters further, an individual’s coping Clinical Manual. Chicago: Quintessence Publishing, 2004
(in print).
Continuity of size and proportions ability varies at a given time or place. Never- 6. Stroebel L, Todd H, Zakia R. Visual Concepts for
Closure by a frame theless, closure, as a psychological concept, is Photographers. New York: Focal Press, 1980.
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IN BRIEF
• The face is the most recognisable feature of the body.
• Philosophers, scientists and sociologists have assigned many personality traits to facial
features.
• Numerous ideas exist for linking facial landmarks to determine and influence the shape of the
maxillary anterior teeth.
• Two key reference lines, interpupillary and incisal, are crucial for anterior aesthetics.
VERIFIABLE
CPD PAPER
Anterior dental aesthetics:

Facial perspective
I. Ahmad1
aesthetics is not merely limited to the ocular apparatus. The concept of aesthetics encompasses both the time-arts such as
music, theatre, literature and film, as well as space-arts such as paintings, sculpture and architecture.
INTRODUCTION professionals. The optical illusion of a white

ANTERIOR DENTAL The face is the first view requiring assessment by band of teeth bordered by red lips is constantly
AESTHETICS
a dental practitioner. This view not only reveals put forward in society, where a perfect smile is
1. Historical perspective the physical landmarks of a person’s identity, but depicted as a monolithic band of ivory (Fig. 1).
2. Facial perspective also gives clues to their psychological make-up In reality, the upper anterior teeth are not a
3. Dento-facial perspective or persona.1 In addition, from an evolutionary white monolithic band bordered by lips, but dis-
4. Dental perspective standpoint, the face is the most recognisable fea- tinct entities with specific proportions and
5. Gingival perspective ture of the body, an innate and learned response embrasures. These facts should be clearly con-
6. Psychological perspective* commencing in early childhood.2 Facial expres- veyed to the patient at the onset of treatment to
sions mirror our emotional states and serve as avoid later disagreements. The reason for the
crucial non-verbal communication tools. Facial apparent illusion of the smile is due to:
* Part 6 available in the BDJ Book muscle contractions convey feelings of fear, joy, • Angle and distance of view
of this series
happiness, anger, etc. without uttering a single • Lighting
word. Depending on the surrounding soft tissue • Profound colour contrast between teeth and
envelope of the lips and cheeks, showing anteri- the lips
or teeth can signify pleasure (by a smile), or dis- • Poor image quality or
dain (by a sneer). These examples illustrate the • Image manipulation.
importance of teeth to the facial composition,
serving the functions of mastication, communi- There are several ways of creating facial
cation and social interaction. Consequently, assessment including physiognomic, mor-
analysis of facial features influences dental phopsychological and geometric. The first two
restorations, particularly in the anterior region,
by integrating with existing skeletal and soft
tissue features to either enhance desirable quali-
ties or distract attention from undesirable abnor-
malities.
The Ridgeway, North Harrow, Middlesex, FACIAL ASSESSMENT
Tel: +44 (0)20 8861 3535, Fax: +44 (0)20 The facial composition is one of the most impor-
8861 6181, www.IrfanAhmadTRDS.co.uk tant issues for the patient. This perspective
Email: iahmadbds@aol.com influences most patients’ notions of a perfect
smile. The reason for this is that most media
Refereed Paper
doi: 10.1038/sj.bdj.4812534 images of beauty focus on the face. The public is
© British Dental Journal 2005; 199: rarely used to scrutinising a smile at close Fig. 1 Media representation of a smile as a monolithic
15–21 distance, in the way routinely done by dental band of ivory bordered by lips
BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005 15

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categories are subjective evaluations based on

ideology, theology, sociology, culture and indi-
viduality, while conversely, geometric appraisal
is an objective evaluation dictated by mathe-
matics, devoid of idiosyncrasies inherent in the
first two categories.
PHYSIOGNOMY
The facial perspective is the deciding factor for
whether a treatment is a success or failure. The
reason is that from this view, the patient, his/her
family and friends make a physiognomic judge-
ment regarding an individual’s character. Phys-
Fig. 2 In the third world, missing teeth are associated
with poverty and misery iognomy is the art of judging an individual’s
character or personality by the appearance of
their face. This skill shares similar features with
palmistry and astrology, dating back to antiqui-
ty, forming part of our collective consciousness.
Although the relevance and meaning of facial
features vary, physiognomic assessment is
prevalent in Eastern and Western cultures.3
Whilst this may seem superficial, it is the com-
monest way of social assessment.
Objectively, the notion that facial features
are responsible for a person’s morality is at best
spurious, and at worst stultifying. However,
what is significant is that objectivity does not
Fig. 3 In the developing world, discoloured teeth are exclusively influence our daily lives. Rather, our
synonymous with misfortune behaviour is predominantly manipulated by
emotional responses.4 This being the case,
physiognomic judgement, which is a subjective
assessment, profoundly affects social interac-
tion.
It follows that if physiognomy plays a part in
assessing people, the teeth, which are important
facial landmarks, must also sway our judge-
ment. This is termed dentofacial physiognomy.
In the USA, for example, a bright white smile
signifies affluence, youth, health, and promotes
career progression. While in Europe, less
emphasis is placed on a ‘plastic’ smile for a ful-
filling life. These trends are simply indigenous
Fig. 5 Fashion trends influence Fig. 4 In some African cultures, anterior gold dental aspects of two cultures; neither is right nor
provision of oral jewellery prostheses signify prosperity
wrong, but merely different.
In Asian and Chinese societies, the number,
size, colour and type of dental restorations are
deciding factors of an individual’s status and
even destiny.5 In the developing world, missing
incisors are synonymous with poverty and
despair, while discoloured teeth portend disaster
and misfortune (Figs 2 and 3). Another example
is that Africans regard having anterior yellow-
gold prostheses as a sign of prosperity (Fig. 4).
Finally, fashion trends and adulation inspire
emulation, e.g. precious stones embedded into
anterior teeth (Fig. 5).
The relevance of this discussion on dento-
facial physiognomy is to raise cultural aware-
ness of ethnic minorities among dental health
providers. Offering ethnic minority patients
dental restorations based on Western mores
will alienate them from their culture and
standing in community. And this will
ultimately deter these patients from seeking
further dental care for themselves and their
families.
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MORPHOPSYCHOLOGY • Facial typology

The study of morphopsychology6 involves • Facial zones and segmental expansion
establishing a link between the morphology of • Sensitive receptors
the human body with psychological make-up. In • Tegumental texture and relief
dentistry, the face is the focus of attention, and • Sexual type
the ensuing discussion on morphopsychology is • Hemifaces.
therefore limited to facial features. The face is a
reflection of our inner soul, influenced by both From a typological perspective, faces are
heredity and environmental factors. The former assigned to one of four categories (Figs 6-9):
is beyond our control, while the latter is control- • Lymphatic (rounded full features with a timid
lable by our will and certitude. Facial analysis is personality)
assessed by the following factors: • Sanguine (prominent thick well-defined features
associated with intransigence and spontaneity)
• Nervous (large forehead, thin delicate
features with an anxious disposition)
• Bilious (rectangular and muscular features
coupled with a dominant persona).
The form of teeth should conform to these

four types, so that for example, providing deli-
cate or fragile looking teeth for a bilious face is
clearly incongruous.
In both the frontal and sagittal views, the
face is divided into three zones: upper, middle
Fig. 6 Facial typology: lymphatic personality and lower. The upper segment is from the hair-
line to the glabella (root of the nose), the mid-
dle from the root of the nose to the subnasale,
and the lower from the subnasale to the soft tis-
sue menton (chin prominence) (Figs 10 and 11).
This morphological differentiation signifies
specific psychological traits: the upper third is
associated with creativity, the middle with
emotions and the lower with instinctive and
sensual activities.
Fig. 7 Facial typology: sanguine personality
Fig. 10 Frontal view of

the three facial
divisions
Fig. 8 Facial typology: nervous personality
Fig. 11 Sagittal view

of the three facial
Fig. 9 Facial typology: bilious personality divisions

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To achieve equilibrium and harmonious inte- have prostheses that convey wear and maturity,
gration, the facial zones (Fig. 12) should be conforming to reduced tone and more wrinkles.
equal quantitatively (morphologically) and Qualities assigned to biological masculinity
qualitatively (psychologically). If one of the and femininity are blatant. Masculine facial
zones is physically larger, say the middle third features display prominent osseous structures,
(emotional), another can compensate for this angular jaw lines, closed facial angle, and rec-
qualitatively, without creating imbalance. In the tangular soft tissue angles, etc. Feminine com-
latter example, placing larger teeth in the lower ponents encompass delicate osseous make-up,
third of the face would counterbalance the oval jaws, open facial angle and rounded soft
physically larger middle third segment. tissues angles, etc. However, in contemporary
society and aberrant life styles, the convention-
al sexual types may be ambivalent. Therefore,
the clinician should ascertain the biological, as
well as preferred sexual type, before prescribing
anterior restorations, which may conflict with
the patient’s overt sexuality.
Finally, hemifaces describe asymmetry of the
right and left sides of a face7 (Fig. 13). This may
be inherited, sequalae of trauma, or determined
by disease or psychologically. Inheritance plays
Fig. 12 a major role for dental element form, alignment,
Morphopsychological colour, etc; the maxillary right and left anterior
equilibrium is realised sextant is rarely identical (Fig. 14) which does
when the facial thirds not often cause visual tension, but adds diversi-
are equal both
quantitatively and
ty and interest to a dental composition. Acci-
qualitatively dents and disease may cause severe disfigure-
ment beyond what is aesthetically acceptable,
necessitating clinical intervention to resolve the
anomalies.
Fig. 13 Asymmetrical
right and left facial Fig. 14 Asymmetrical right and left anterior maxillary
halves (hemiface) sextant
Each of the facial zones is assigned a sense Lastly, from a psychological aspect, the right
organ (or receptor), the upper third: the eyes, the and left brain hemispheres are responsible for
middle: the nose and the lower: the lips. The different cerebral activities. For a right-handed
vestibular frame of the facial map of the face person, the left side of the brain, controlling the
encloses these receptors, which can be either right part of the face, is responsible for cogni-
open or closed. Wide eyes, dilated nostrils and tive, computational and practical activities,
voluptuous lips have obvious psychological sig- while the right side (controlling the left part of
nificance of welcome, arousal and sensuality, the face) for creative and conceptual ideas. A
respectively. Conversely, closed receptors con- sentimental social disaster may result in sag-
vey the opposite connotations of alienation, ging (reduced muscle and skin tonicity) to the
passivity and frigidity. A wide, curved, round left facial middle third (ascribed to emotions
angled tooth form is appropriate for patients and feelings), which could be compensated by
with open receptors and vice versa for those providing appropriate anterior teeth in the
with closed receptors. maxillary anterior right sextant.
The degree of tegumental relief is inherited,
but laxness increases with advancing years. GEOMETRIC
Rough, pitted and textured skin requires teeth The final, and most objective, method of facial
with similar characteristics, while smooth silky assessment is based on mathematical principles
soft tissue yearns for a glossy, smooth dentition. of evaluating beauty. Methods for quantifying
In addition, younger patients with increased skin beauty preoccupied ancient Greeks, and have
tone should have restorations that correspond to mystified philosophers and scientists throughout
their vitality, while older generations should the centuries. A review of the dental literature

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shows numerous, ingenious criteria for dental

harmony which complement facial features.8
None of these observations has scientific founda-
tion, since facial features and tooth form are
determined genetically.9 The facial characteris-
tics of a sibling may be inherited from one par-
ent, while tooth morphology from the other par-
ent. Therefore, facial characteristics have no
correlation to tooth shape, size, colour, align-
ment, etc. However, there is consensus that cer-
tain proportions (both facial and dental) are psy-
chologically perceived as visually pleasing. This
dictum is the basis of mathematical analysis of
facial attractiveness. Fig. 15 Horizontal and
The following discussion on geometrical vertical facial lines in
the front view
evaluation should be regarded as a general
framework, since an object created with mathe-
matical precision, which is scarcely observed in
nature, will undoubtedly be perceived as artifi-
cial. The reason is that such perfection is a rarity,
and sensed as a fake or simulation. The latter is
particularly true of computer graphics, which try
to emulate objects and beings with precision,
ignoring nuances prevalent in the natural world.
While ideal facial features may be related to the
Golden proportion, they have little significance in
dentistry. However, in plastic or reconstructive
surgery, facial landmarks according to the Golden Fig. 16 It is not
proportion are valuable guidelines for the surgical obligatory for all the
team. A geometric evaluation of the face is visual- facial horizontal lines
ising imaginary lines in the frontal and sagittal to be parallel to gain
views. Commencing from the upper to the lower aesthetic approval
parts of the face, the horizontal lines are:
• Hair
• Ophriac
• Interpupillary
• Interalar
• Commissural.
These parallel lines create horizontal symme-

try and act as cohesive forces unifying the facial
composition. The facial midline is perpendicular
to the horizontal lines and opposes their cohe-
siveness. The latter are termed segregative Fig 17. Ideally, the
interpupillary line
forces and are essential in a composition to give should be parallel to
it interest and harmony (Fig. 15). The cohesive the incisal plane and
forces are paramount in achieving pleasing aes- perpendicular to the
thetics; the deviation of the facial midline is facial midline
secondary and varies in many individuals with-
out a deleterious effect. It is the general paral- the tilting could be due to a slanted maxilla. It is
lelism of the horizontal lines, which is impor- vital to determine which factor is responsible
tant, as opposed to the orientation of one single for the misalignment of the incisal plane, as this
line.10 The interpupillary line is used as a will have a profound impact on the proposed
reference for the occlusal and incisal plane ori- treatment plan. The frontal view also enables
entations. The other horizontal lines can be assessment of whether the patient has an open
eschewed and therefore do not act as definite or closed bite, following posterior tooth loss,
references; they are however, useful accessory resulting in a diminished linear dimension of
markers (Fig. 16). The incisal edges of the ante- the lower third of the face.
rior teeth should be parallel to the interpupillary As mentioned above, the interpupillary and
line and perpendicular to the midline (Fig. 17). incisal lines are essential reference markers in
If the incisal plane is tilted this could be attrib- prosthodontics. The latter are conveyed to the
uted to dental or skeletal factors. The dental fac- ceramist for articulation by means of a facebow
tors that influence the incisal table are attrition, transfer. Caution is advised when using a
erosion (e.g. gastric regurgitation as in bulimia), facebow, since the right and left soft tissue
abrasion, altered patterns of eruption and peri- auditory meatus may be at different levels. A
odontal disease. If the latter are eliminated, then discrepancy in the intercondylar axis results in

1p15-21.qxd 15/06/2005 16:44 Page 20
PRACTICE
differences between the functional and aesthet-

ic planes of occlusion. The best method to avoid
this inaccuracy is by aligning the facebow so
that it coincides with the interpupillary line
(Figs 18 and 19). Other auxiliary methods, com-
plementing a facebow, are using either a spirit
level or an applicator stick bite (Figs 20 and 21).
The case study in Figures 22 and 23 shows a
clinical example for rectifying disparate inter-
pupillary and incisal plane lines. (The book ver-
sion of this article will show a detailed clinical
sequalae for achieving the latter).
Fig. 22 Pre-operative status showing disharmony
between interpupillary and incisal plane lines
Fig. 18 Correctly
positioned facebow
viewed from frontal
aspect
Fig. 23 Post-operative status showing coincidence

between interpupillary and incisal plane lines
From the sagittal aspect, the horizontal lines

also reinforce the cohesiveness of the profile
(Fig. 24). In addition, the Frankfurt horizontal
plane, Rickett’s E-plane,11 the Steiner12 or Bur-
stone13 lines and the nasolabial angle also con-
tribute to profile assessment. Two are consid-
ered below in detail, the Rickett’s E-plane and
Fig. 19 Correctly
positioned facebow the nasolabial angle, which ascertain the pro-
viewed from sagittal trusion or retrusion of the maxilla as well as lip
aspect competence. In addition to soft tissue analysis,
cephalometric reference points are invaluable
for assessing the profile. The latter will distin-
guish between soft tissue and skeletal abnor-
malities and reveal Angle, Class I, II or III jaw
relationships.14
Fig. 20 Applicator
stick bite parallel to
interpupillary line
viewed from frontal
aspect
Fig. 24 Horizontal facial lines viewed from sagittal
The nasolabial angle is the intersection of

two lines using the nose and lips as reference
points. The two lines are tangents of the sub-
Fig. 21 Applicator nasale and the maxillary lip profile (Fig. 25).
stick bite parallel to
interpupillary line For males, this angle rages from 90° to 95°
viewed from sagittal and for females from 100° to 105°. Assuming
aspect 90° as the normal, if the nasolabial angle is

1p15-21.qxd 15/06/2005 16:46 Page 21
PRACTICE
<90°, the maxilla is prominent and a convex

facial profile is manifested. In this case,
recessed maxillary anterior restorations are
considered. If the reverse is present, manifest-
ing a concave profile, i.e. nasolabial angle is
>90°, a prominent maxillary anterior dental
segment is indicated. Spear15 has termed this
concept of facial profile to determine the
position, and degree of dominance, of the
maxillary anterior teeth as ‘facially generated
treatment planning’.
The Rickett’s E-plane is a line drawn from the
nose tip to the chin prominence. Accepted
norms for the distance from the maxillary lip to
this imaginary line are 4 mm, while that for Fig. 25 Nasolabial
angle (gold coloured)
mandibular lip is 2 mm (Fig. 26). With edentu-
lous cases, it is imperative to restore the Rick-
ett’s E-plane to establish a correct facial profile.
For example, in edentulous cases, the maxillary
lip is unsupported and the measurement to the
E-plane is greater than 4 mm, indicative of a
deficient facial profile (Fig. 27). Consequently,
when artificial prostheses are fabricated, the
latter should re-establish lip support and restore
the facial profile (Fig. 28).
CONCLUSION
Facial assessment is both subjective and objec-
tive. Physiognomy and morphopsychology are
subjective methods of appraisal, while geomet-
ric is an objective analysis. It is the combina- Fig. 26 Rickett’s
E-plane
tion of the two that achieves dental restorations
which integrate with facial features and are
perceived with aesthetic approval. However,
the ultimate result is heavily dependant on the
clinician’s and the ceramist’s creativity and
artistic input.
1. Jung CG. Dreams. Princeton University Press, Princeton,
New Jersey, 1974.
2. Myers DG. Psychology, Worth Publishers, Inc., New York,
1998.
3. Hassin R, Trope Y. Facing faces: studies on the cognitive
aspects of physiognomy. J Pers Soc Psychol 2000; 78:
837–852.
4. Armstrong E. The limbic system and culture: an allometric
analysis of the neocortex and limbic nuclei. Human Nature
1990. Fig. 27 Unsupported
5. McGarth C, Lui K S, Lam C W. Physiognomy and teeth: An maxillary lip resulting
ethnographic study among young and middle-aged Hong in a deficient facial
Kong adults. Br Dent J 2002; 192 (9): 522–525. profile
6. Rufenacht CR. Fundamental of Esthetics. Quintessence
Publishing Co. Inc., Chicago, Il, 1990.
7. Gebhard W. A comprehensive approach for restoring esthetic
and function in fixed prosthodontics. QDT 2003; 26: 21–44.
8. Levin E I. Dental aesthetics and the golden proportion. J
Prosthet Dent 1978; 40: 244–252.
9. Lehman W. Tooth form and the face: A comedy of errors.
South Calif State Dent J 1950; 17: 29.
10. Chiche, GJ and Pinault A. Esthetics of Anterior Fixed
Prosthodontic. Quintessence Pub Co.Inc., 1994: 1; 15.
11. Levin JB. Esthetic diagnosis. Current Opinion in Cosmetic
Dentistry, Current Science, 1995: 9–17.
12. Weickersheimer P B. Steiner analysis. In: Jacobson A ed.
Radiographic Cephalometry. Carol Stream, Il: Quintessence
Publishing; 1995: 83-85. Fig. 28 Following
13. Burstone C J. Lip posture and its significance in treatment provision of maxillary
planning. Am J Orthod 1967; 53: 262–284. prostheses, the upper
14. Rifkin R. Facial analysis: A comprehensive approach to
lip is now supported,
treatment planning in aesthetic dentistry. Pract Periodont
Aesthet Dent 2000; 12 (9): 865–871.
restoring the facial
15. Spear F. Creating Esthetic Excellence Part I, A Complete profile (compare with
Approach. Presented at the ADA Meeting in Las Vegas, 1995. Fig. 27)

2p81-88.qxd 11/07/2005 15:45 Page 81
3
IN BRIEF
• The degree of anterior tooth display is determined by the lips at rest and during smiling.
• The LARS factor guides amount of tooth exposure in the static muscular position of the lips.
• A smile is determined by the dynamic muscular position of the lips.
VERIFIABLE
CPD PAPER

Dentofacial perspective
I. Ahmad1
INTRODUCTION the lips in relation to the anterior maxillary sex-

ANTERIOR DENTAL The third paper in this series on anterior maxil- tant. The deeper colour of the lips compared
AESTHETICS
lary dental aesthetics discusses the dento-facial with lighter coloured teeth creates a colour con-
1. Historical perspective view. This perspective concentrates on the oro- trast to add interest to this arrangement. The
2. Facial perspective facial landmarks consisting of highly vascu- dento-facial composition encompasses both the
3. Dento-facial perspective larised lips with the teeth acting as a gateway to frontal and sagittal planes in two muscular
4. Dental perspective the oral cavity. The emphasis here is to analyse positions; the static and dynamic (Figs 1 to 4).
5. Gingival perspective
6. Psychological perspective*
* Part 6 available in the BDJ book

of this series
Fig. 1 Sagittal view of the static position of the Fig. 3 Frontal view of the static position of the
dento-facial composition with relaxed orofacial muscles dento-facial composition with relaxed orofacial muscles

Tel: +44 (0)20 8861 3535, Fax: +44 (0)20
Refereed Paper
doi: 10.1038/sj.bdj.4812412 Fig. 2 Sagittal view of the dynamic position of the Fig. 4 Frontal view of the dynamic position of the
© British Dental Journal 2005; 199: dento-facial composition with contracted orofacial dento-facial composition with contracted orofacial
81–88 muscles during a relaxed smile muscles during a relaxed smile

2p81-88.qxd 11/07/2005 15:46 Page 82
PRACTICE
STATIC The length of the upper lip varies from 10-

The static position is when the lips are slightly 36mm, and individuals with long maxillary lips
parted and the teeth are out of occlusion with the show more mandibular rather than maxillary teeth.
perioral muscles relatively relaxed. This position The amount of tooth exposure at rest is predomi-
is typically achieved following utterance of the nantly a muscle-determined position (Table 1).
letter ‘M’. In this tranquil position, four factors
influence tooth exposure: lip length, age, race and Table 1 Maxillary lip length in relation to anterior
sex, also known as the acronym LARS (Figs 5-8).l,2 tooth exposure
Maxillary lip Maxillary lip Exposure of Exposure of
classification length (mm) upper lower
central incisor central incisor
(mm) (mm)
Short 10-15 3.92 0.64
Medium 16-20 3.44 0.77
Fig. 5 The LARS Medium 21-25 2.18 0.98
factor to determine Long 26-30 0.93 1.95
the amount of Long 31-36 0.25 2.25
tooth exposure at
rest. Lip length: the
linear measurement
of the upper lip. The Age is the second part of the LARS factor,
patient depicted has which in a similar way to lip length, influ-
a medium maxillary
lip length
ences the amount of tooth visibility. The
amount of maxillary tooth displayed is
inversely proportional to increasing age
whereas the amount of mandibular teeth is
directly proportional to increasing age. There-
fore, a young person will display more maxil-
lary than mandibular teeth, whereas an older
individual will show more mandibular, rather
than maxillary teeth:
Fig. 6 The LARS • Maxillary incisor tooth visibility (inversely
factor to determine proportional to age)
the amount of • Mandibular incisor tooth visibility (directly
tooth exposure at
proportional to age).
rest. Age: an elderly
individual showing
only the lower People age at differing rates because ageing
incisors is a multi-factorial phenomenon described by
the three Ps: programmed, pathological, and
pychological ageing.
During youth, the process of destruction and
formation of cells is in equilibrium. With
advancing years the balance shifts in favour of
increased destruction and reduced replacement
of body tissues. This change is called pro-
grammed or physiological ageing, and is trig-
Fig. 7 The LARS
factor to determine
gered by an internal ‘biological clock’. Why and
the amount of when this change occurs is still unknown.
tooth exposure at Pathological ageing is due to diseases of the
rest. Race: black oral environment leading to accelerated tissue
individuals reveal degradation. For example, if anterior teeth are
less maxillary teeth
than Caucasians lost due to refractory periodontitis, premature
formation of nasolabial grooves is evident.
Finally, when feelings of fatality prevail over
those of existentialism3, due to emotional and
personal traumas, changes in the psyche are
observed. These psychosomatic changes mani-
fest themselves as psychological ageing.
The result of the three Ps of ageing is
Fig. 8 The LARS reduced tonicity of the orofacial muscles and
factor to determine laxness of tegumental relief in the lower third
the amount of of the face resulting in formation of the labial,
tooth exposure at nasolabial and mental grooves and ridges (Fig.
rest. Gender:
9). The loss of elasticity of the upper lip, with
females show nearly
twice the amount of decreasing tooth support by the gingival 2/3 of
upper teeth than the maxillary incisors, accounts for less maxil-
men lary and more mandibular incisor tooth display.

2p81-88.qxd 11/07/2005 15:48 Page 83
PRACTICE
THE DYNAMIC POSITION

The second constituent of dento-facial compo-
sition is the dynamic position, typically char-
acterised by a smile. The extent of tooth expo-
sure during a smile depends on skeletal
make-up, degree of contraction of the facial
muscles, shape and size of the dental elements
and shape and size of the lips, which vary from
extremely thin to full and thick (Figs 12 and
13). According to Rufenacht’s morphopsycho-
logical concepts, individuals with thin and
taut lips should be provided with teeth which
Fig. 9 An edentulous 50-year-old woman showing
pathological ageing due to premature loss of all her confer delicacy and fragility. Conversely,
dentition in her twenties, resulting in development of patients endowed with thick or voluptuous lips
the nasolabial grooves and ridges require teeth which display dominance and
boldness.
The last two determinants of the LARS factor
are race and sex. A decreasing amount of max-
illary, and an increasing amount of mandibular
tooth visibility, is seen from Caucasians to
Asians to Blacks, while the last constituent is
the sex of the individual.
Males generally have longer maxillary lips
than females, leading to an average maxillary
tooth display of 1.91 mm for men and 3.40
mm for women. Consequently, gender differ-
ences account for females displaying nearly
twice the amount of maxillary teeth compared
with men.
In conclusion, before the amount of tooth Fig. 12 Frontal view of woman with thin, taut lips
exposure at rest is prescribed for the proposed
prostheses, each patient should be assessed
according to the LARS factor, e.g. an increased
maxillary tooth exposure is indicated for young
females, and the opposite for elderly males (Figs
10 and 11).
Fig. 13 Frontal view of woman with thick, voluptuous

lips
Whereas in the facial composition horizon-

tal symmetry was the most important factor,
Fig. 10 Young females display a greater degree of the in the dento-facial view it is radiating symme-
upper anterior teeth due to pronounced tonicity and try that takes precedence. Radiating symmetry
shorter maxillary lips is defined as an object having a central point,
from which the right and left sides are mirror
images.4 In this view, the fulcrum, or central
point is the maxillary dental midline, and the
right and left upper anterior teeth are bal-
anced mirror images. However, due to differ-
ing wear patterns of the incisal edges, this
ideal is uncommon. Lack of radiating symme-
try is not crucial, so long as there is balance
on the right and left sides of the anterior
dental segment.
Cohesive forces, as in the facial composition,
add interest to the dentofacial composition.
Fig. 11 Elderly males show little, or no, upper teeth but These are created by parallelism of the incisal
more lower teeth due to tegumental laxness and longer (lime green) and commissural (blue) lines, with
maxillary lips the segregative force of the dental midline

2p81-88.qxd 11/07/2005 15:52 Page 84
PRACTICE
(yellow) intersecting at 90 degrees (Fig. 14). THE SMILE LINE

Placement of the dental midline has evoked The smile line is an imaginary line running from
considerable controversy in dental literature. the incisal edges of the maxillary incisors and
One school of thought states that the maxillary coinciding with the curvature of the lower lip.
dental midline should coincide exactly with the When the incisal plane is not parallel with the
labial fraenum and the facial midline5, as it does curvature of the lower lip then flat, eccentric or
in 70% of the population. The opposing view is reversed smile lines are evident. This coincidence
that placing the midline exactly in the centre between the incisal table and the mandibular lip
may contribute to a sense of artificiality.6 The is often lost due to wear by abrasion, erosion or
choice of where to place this midline should be attrition (Fig. 16), periodontitis (Figs 17 and 18),
determined after aesthetic appraisal. If a domi- altered patterns of eruption (Fig. 19) or poor
nant central point of focus exists, e.g. a maxil- quality dentistry (Figs 20 and 21).
lary median diastema, then the midline should
be placed with this focal point as the fulcrum.
Another reason for placing a vertically aligned
midline precisely in the centre is to detract
attention from asymmetries and disharmonies
of the face. Opticians and the cosmetic industry,
Fig. 14 (top) Coincidence of the with dramatic visual effect, exploit this concept
incisal plane (lime) with the of guiding the eye to a particular point of focus
commissurat line (blue). The yellow
line depicts the maxillary dental on the face to mitigate blemishes or undesirable
midline intersecting the horizontal facial features. Alternatively, a slightly off-cen-
lines at 90° tre placement of the dental midline in relation Fig. 16 Lack of parallelism of the maxillary incisal plane
to the facial midline is not detrimental to aes- with curvature of the mandibular lip due to pronounced
Fig. 15 (bottom) Lack of wear of the maxillary teeth
coincidence of the facial midline
thetic approval (Fig. 15). The mandibular mid-
(red) with the maxillary dental line should not be used as a reference point,
midline (yellow) is not a prerequisite because in 75% of the population this does not
for aesthetic approval coincide with the maxillary midline.7
Fig. 17 Refractory periodontitis leading to over-eruption of

the lateral incisors leading to disruption of the incisal plane
in relation to the mandibular lip curvature (see Fig. 18)
Fig. 18 Dento-facial view of patient in Fig. 17 showing

disharmony of the maxillary incisal plane in relation to
the mandibular lip curvature
Fig. 19 Altered eruption patterns of maxillary teeth

resulting in an eccentric incisal plane, not parallel with
the mandibular lip curvature

2p81-88.qxd 11/07/2005 15:53 Page 85
PRACTICE
Similar to a painting, the anterior and lateral

negative spaces act as a border to the dental ele-
ments, with the lips representing the picture
frame. Anterior negative space is evident during
both speech and laughter (Fig. 24), while bilat-
eral negative spaces should be evident during a
relaxed smile (Fig 25). These negative spaces Fig. 24 Anterior
provide cohesiveness to the dento-facial com- negative space evident
position, and are also in the Golden proportion during speech and
to the anterior dental segment.8 laughter
Fig. 20 Iatrogenic dentistry leading to a revered incisal

plane in relation to the mandibular lip curvature
Fig. 21 Flat incisal plane due to short crowns on the

central incisors and lack of anterior-posterior incisal
embrasure progression
Frequently, this is observed in old removable

full dentures, where the acrylic teeth show an
uneven wear pattern. This leads to an eccentric
smile line, not coincident with the curvature of
the mandibular lip. Therefore, replacement of
the prostheses with new teeth should endeavour
to restore the smile line, ensuring parallelism
with the lower lip during a relaxed smile (Figs
22 and 23).
Fig. 22 Wear on acrylic teeth of removable full denture

lacking parallelism with mandibular lip curvature
To summarise, there is no such thing as a Fig. 25 Infrared
perfect smile, however for the sake of defining photograph showing
bilateral negative
guidelines for prosthodontics, the constituents spaces bounding the
of an ideal smile are when: anterior dental
• The upper anterior teeth coincide with the cur- segment
vature of the mandibular lip during a relaxed
smile
• The corners of the lips are elevated to the
same height on both sides (termed smile
symmetry)
• Bilateral negative spaces are evident, separat-
ing the teeth from the corners of the lips.
Fig. 23 Replacement of removable full denture (for
patient in Fig. 22) with restitution of incisal plane, Additionally, the contact points of the anteri-
which is parallel with mandibular lip curvature or dental segment should also coincide with the

2p81-88.qxd 11/07/2005 15:55 Page 86
PRACTICE
incisal edges and with the curvature of the Additionally, the dentofacial composition
lower lip, thus enhancing the cohesiveness of revealed an undulating (roller-coaster) incisal
the dentofacial composition (Figs 26 and 27). plane, in conflict with the lower lip curvature,
which was neither parallel to the commissural
line (blue), nor the gingival exposure line
(white) (Fig 30 and 31). Finally, in the dental
composition, a myriad of flaws were evident,
including diastemae, wear, and a lack of Golden
proportion progression.
Fig. 26 Sagittal view of ‘ideal’ smile line

(see text for explanation)
Fig. 30 Undulation, ‘roller-coaster’ incisal plane
Fig. 27 Frontal view of ‘ideal’ smile line

(see text for explanation)
CASE STUDY
This case study highlights some of the points
discussed above, and how these concepts can be Fig. 31 Incisal plane (lime) is neither parallel to
used to achieve optimum dental aesthetics. commissural (blue), nor gingival (white) lines
A 60-year-old lady attending the practice
sought aesthetic improvement of her maxillary The treatment plan to resolve these aesthetic
anterior segment. The preoperative views anomalies consisted of porcelain laminate
showed unsightly composite fillings in teeth 13, veneers on teeth 13, 12 and 22, full coverage
12, 11, 21 and 22. The left canine was the anteri- ceramic crowns on the maxillary centrals, and a
or abutment of a defective three-unit fixed par- new three-unit ceramo-metal fixed partial
tial denture (Figs 28 and 29). denture with teeth 23 and 25 as abutments and 24
as the pontic. The completed tooth preparations
for these restorations are shown in Figs 32-35.
Fig. 28 Frontal view showing

pre-operative status
Fig. 32 Right lateral view of completed tooth preparations
Fig. 29 Occlusal view showing

pre-operative status Fig. 33 Frontal view of completed tooth preparations

2p81-88.qxd 11/07/2005 15:57 Page 87
PRACTICE
Fig. 34 Left lateral view of completed tooth

preparations
Fig. 38 Completed
definitive restorations
Fig. 35 Occlusal view of completed tooth preparations showing correction of
the maxillary incisal
After impressions and plaster casts were made plane
(Figs 36 and 37), new restorations were fabricat-
ed to correct the anomalies mentioned above.
Fig. 39 Right lateral view of cemented prostheses
Fig. 36 Final impressions with an addition silicone

material
Fig. 40 Occlusal view of cemented prostheses
Fig. 37 Plaster cast of tooth preparations
The finished restorations show restitution of

the maxillary incisal plane (Fig. 38). The ceram-
ics in this case study were kindly done by Willi
Geller (Oral Design, Zurich, Switzerland). Post
cementation, the ceramic veneers and crowns
blended impeccably with the fixed partial den-
ture, with optimal gingival health depicted by
formation of the gingival groove, knife edge
gingival margins and stippling of the attached
gingivae (Figs 39-41). Fig. 41 Left lateral view of cemented prostheses

2p81-88.qxd 11/07/2005 15:59 Page 88
PRACTICE
The maxillary incisal plane was now parallel

with the curvature of the mandibular lip and to
the commisural (blue) and gingival exposure
lines (Figs 42 and 43). Pre- and post-operative
facial views showed the transformation and
rejuvenation of the patient from being dejected
and forlorn to a vivacious and confident per-
sona (Figs 44 and 45).
Fig. 44 Pre-operative facial view
Fig. 42 Parallelism of incisal plane (lime) with

commissural (blue) and gingival (white) lines (compare
with Fig. 31)
Fig. 45 Post-operative facial view
1. Vig R G, Brundo G C. The kinetics of anterior tooth display.

J Prosthet Dent 1972; 39: 502.
2. Ahmad I. Geometric considerations in anterior dental
aesthetics: restorative principles. Practical periodontics and
aesthetic dentistry, 1998; 10: 813–822.
3. Satre J P. The age of reason. Hamish Hamilton, 1947.
4. Rufenacht C R. Fundamental of aesthetics. Chicago:
Quintessence Publishing Co Inc, Il, 1990; 1: 18.
5. Heartwell C M. Syllabus of complete dentures. Philadelphia:
Pa: Lea and Febiger, 1968.
6. Dental Office Procedures. CA: Swissedent Foundation, 1990.
7. Miller E C, Sodden E R, Jamison H C. A study of the
relationship of the dental midline to the facial median line.
J Prosthet Dent 1979; 41: 657–660.
Fig. 43 Maxillary incisal plane coincident with 8. Levin El. Dental esthetics and the golden proportion.
curvature of mandibular lip (compare with Fig. 30) J Prosthet Dent 1978; 40: 244–252.

3p135-141.qxd 18/07/2005 11:38 Page 135
4
IN BRIEF
• The shape, length and width of maxillary anterior teeth are open to interpretation, including
mathematical, physiological and psychological.
• Tooth alignment, in three dimensions, creates a pleasing tooth-to-tooth progression.
• The position of the teeth in the dental arches also ensures correct phonetics and occlusion.
VERIFIABLE
CPD PAPER

Dental perspective
I. Ahmad1
INTRODUCTION and triangle (Fig. 1). These shapes are analo-

ANTERIOR DENTAL The dental perspective concerns the teeth, gous to the primary colours (red, green and
AESTHETICS
their shape, size, intra- and inter-arch rela- blue), from which any colour can be created.
1. Historical perspective tionships. The fourth paper in this series on Similarly, any shape can be created from a circle,
2. Facial perspective anterior maxillary dental aesthetics discusses square or triangle. The unique composite mor-
3. Dento-facial perspective novel and redundant concepts for these dental phology of the teeth allows diversity and indi-
4. Dental perspective elements. Numerous hypotheses have been viduality. Essentially, no two teeth are ever
5. Gingival perspective postulated and dismissed emphasising, as with alike, but all share the same geometric building
6. Psychological perspective* general principles of aesthetics, that empirical blocks. This configuration has allowed nature
knowledge takes precedence over dogmatic carte blanche to produce inimitable shapes
scientific laws. based on only three variables. Emphasising one
* Part 6 available in the BDJ book shape and suppressing the others, has promoted
of this series
SHAPE manufacturers of artificial teeth for dental
The morphology of maxillary anterior teeth is a prostheses to classify teeth as circular, rectan-
fusion of the three basic shapes: circle, square gular or triangular.

Tel: +44 (0)20 8861 3535, Fax: +44 (0)20
Refereed Paper Fig. 1 The three basic

doi: 10.1038/sj.bdj.4812569 shapes circle, square
© British Dental Journal 2005; 199: (rectangle) and
135–141 triangle
BRITISH DENTAL JOURNAL VOLUME 199 NO. 3 AUGUST 13 2005 135

3p135-141.qxd 18/07/2005 11:20 Page 136
PRACTICE
The shape of the maxillary anterior teeth has of the central incisor was the inverted frontal
been the subject of numerous studies. The view of the face, while Frush and Fisher sug-
most prominent are by Williams1 and Frush gested that sex, age and personality related to
and Fisher.2-4 Williams proposed that the shape the contour of the anterior dental segment.
Williams’ theory was invalidated by subse-
quent studies.
The Frush and Fisher concept is concerned
with the dominance of the central incisors and
their wear in advancing years. It is worth not-
ing that the chronological age of a patient
might not coincide with the dental age. In cases
where a patient has pronounced wear, either by
local or systemic causes, the dental age may be
greater than the chronological age (Fig. 2). The
opposite is evident for older individuals with
sharp incisal edges and pronounced incisal
Fig. 2 Maxillary
central incisors with embrasures, conveying a youthful dental
worn incisal edges, appearance (Fig. 3). Other theories have
conveying an aged proposed correlating tooth shape with skeletal
dentition and soft tissue landmarks, but these ideas have
proved inconclusive. The shape of teeth is
genetically determined and the prosthodontist
should, if possible, obtain pictures of a patient’s
relatives before determining the shape of the
definitive prosthesis.
If no records are available, the points to con-
sider are age, sex, race, and personality. For
example, youthful teeth are sharp, having
unworn incisal edges; with the central incisors
dominating the composition, and in harmony
with the laterals and canines. The reverse is
Fig. 3 Virgin maxillary
central incisors with
true for an older dentition, ie blunt incisal
pristine unworn incisal edges and wear and attrition without conclu-
edges and sive dominance of the maxillary central inci-
developmental lobes sors. Sociologically, stereotypes are readily
recognised and associated with specific indi-
viduals. These divisions are culturally specific
and relevant to a particular country or demo-
graphic locality. For example, it is generally
recognised that females display curvaceous
features (both facially and bodily), devoid of
sharp line angles. On the other hand, masculin-
ity is associated with ruggedness and sharp line
angles. The process of transposing these gender
variations onto the shape of the teeth (Figs 4
Fig. 4 Feminine teeth: and 5) is a concept termed morphopsychology
Curvaceous outlines, (see part 2: Facial perspectives).
devoid of shape line Finally, personality is significant for per-
angles. Also, notice the
ception of an individual in society. A gregari-
mesial inclination of
the lateral incisors ous, vivacious persona is linked to an efferves-
cent personality, while a sombre, reclusive
character is perceived as bland and unsociable.
Once again, these stereotypes are influenced
by upbringing, intellect, culture, and theology.
Linking these traits to dental morphology is
conforming purely to society’s perception of
an individual. Making teeth, which are bright,
bulbous, and prominent, are appropriate for an
outgoing person. Conversely, teeth that con-
vey subtlety with a lower value, and hence are
Fig. 5 Masculine less conspicuous, may be more suited to an
teeth: Rugged outline,
dominance of the introvert.2 Personality traits are discussed fur-
central incisor and ther in the sixth and final article entitled Psy-
distal inclination of the chological perspective, which looks at the psy-
lateral incisors chological influence of our cerebral perception
(compare with Fig. 4)
to the dentition.
136 BRITISH DENTAL JOURNAL VOLUME 199 NO. 3 AUGUST 13 2005

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SIZE
Tooth size is determined by mesio-distal width
divided by the inciso-gingival length, which
yields the width/length (w/l) ratio (Figs 6 and 7):
width
width/length (w/l) ratio of a tooth =
length
No definitive value for the w/l ratio exists and
experts dispute its value. The mesio-distal width is
more important than the inciso-gingival length3
and the former measurement has attracted much Fig. 6 Measuring the
debate. Research has focused on measurements of mesio-distal width of
extracted teeth, racial and gender differences, the central incisors
together with facial landmarks such as the bizygo- with callipers
matic width. House and Loop4 postulated that the
mesio-distal measurement of the central incisor
was 1/16 of the bizygomatic width. Other studies
have also sought to assign geometric values for
the mesio-distal width of the centrals, eg 1/16 of
the face height or the width of the iris.5
There are two schools of thought regarding
the size of the maxillary central incisors. The
first is by Rufenacht6 who proposed mor-
phopsychological determination of an ideal
proportion, and suggested that the width and
length of the central incisor should be con-
stant throughout life. This view relies on the Fig. 7 Measuring the
inciso-gingival length
philosophical notion of eternal youth as
of the central incisors
described by French writer Robert Brasillach with callipers
who said, ‘in life only one youth exists and we
pass the rest of our days regretting it’. While
this statement may seem romantic, many
regard it as sacrosanct and seek a myriad
options to stave off our ‘final destination’.
Bearing this in mind the clinician’s role is not
to act as judge, but as a conduit for patients’
desires. If a person seeks such an option, the
dental team should try not to deny a patient’s
wishes.
The second theory states that our bodies are
in perpetual change throughout life. We are Fig. 8 Youthful teeth:
born small, become taller, and eventually lose Textured surface
height in advancing years. Our skin has tone roughness, visible
and suppleness in youth but becomes flaccid perikymata and bright
enamel
and dull as we grow older. The dentition is no
exception to this transformation. When the
central incisors erupt, they are pristine with
defined incisal lobes, a textured surface rough-
ness, bright enamel, with a smaller w/l ratio
(Fig. 8). During normal functioning, excluding
the effects of disease, the incisal edges wear
(resulting in a larger w/l ratio), surface texture
becomes smooth, and the enamel dulls due to
increased translucency (Fig. 9). These processes
are congruous with the ageing of the rest of the
body. Creating teeth with a youthful appear- Fig. 9 Aged teeth:
ance is discordant in an older person and creates Smooth surface
roughness, stained
a sense of artificiality. fracture lines and a low
The evidence behind each theory is incon- value, dull enamel
clusive and each concept is still open to discus- overlay
sion. Furthermore, the overriding factor in any
case is a patient’s wish including their percep- Firstly, the w/l ratio of the central incisor
tion of themselves in society. Nevertheless, should range from 0.75 to 0.8, a value less than
general guidelines are useful for creating a 0.6 creates a long narrow tooth, and beyond
pleasing result. this number results in a short wide tooth

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with a width gauge, at the junction of the middle

third and incisal third of a tooth (Fig. 13). For a
crown, if a reading of more than 3.5 mm is appar-
ent, then over-contouring of the prosthesis is sus-
pected, usually because of under-preparation by
the clinician leaving the ceramist inadequate
room for the porcelain layer build-up, resulting in
a bulbous crown. If the thickness of a tooth is less
than 2.5 mm, elective endodontic therapy may be
necessary to achieve the desired aesthetics. In
cases where a tooth is inclined facially or lingual-
ly, and the proposed prosthetic treatment is to
simulate its location beyond 2 mm, interceptive
orthodontic therapy may be mandatory.8
Fig. 10 Width/length ratio (w/l): the (Fig. 10). Secondly, the central incisor should be INTRA-ARCH RELATIONSHIP
blue tooth has a w/l ratio of 0.8, the the dominant element in the anterior dental com- Having established guidelines for shape and
red (‘ideal’) 0.75, and the green 0.6 position (Fig. 11). Lastly, the vertical overbite in dimensions of the maxillary anterior segment,
relation to speech and anterior guidance needs and in particular that of the central incisor, the
addressing (Fig. 12). Besides these fundamental next point to consider is the relationship
principles, subtle variations can be introduced between incisors and canines. The tooth-to-
which account for gender, race, facial, mor- tooth relationship frequently relies on the Divine
phopsychological, and psychological factors. (or Golden) proportion and dynamic symmetry,
The buccolingual thickness shows wide vari- initially proposed by the ancient Greeks.
ance, ranging from 2.5 mm to 3.3 mm for the max- In 530BC Pythagoras suggested beauty could
illary central incisors.7 The thickness is measured be defined as an exact mathematical concept,
which led to the Divine or Golden proportion
(1/1.618=0.618). Similarly, Plato proposed the
Beautiful proportion (1/1.733=0.577) as the
quintessential ratio for beauty. Both ideas stated
that an object with these proportions had innate
beauty. The most widely used concept in den-
tistry is the Golden proportion — where S is the
smaller and L the larger part:
S L 2
= = = 0.618
Fig. 11 The dominance of the L S+L 1 + √5
central incisor is paramount for
pleasing anterior maxillary
aesthetics
The uniqueness of this ratio is that when
applied by three different methods of calcula-
tions, linear, geometric and arithmetic, the pro-
portional progression from the smaller to the
larger to the whole part always produces the
same results. Lombardi9 and Levin10 have trans-
posed this ratio to the maxillary anterior sextant
(Fig 14). Other researchers11 have indicated that
clinically the Golden proportion is not always
Fig. 12 Overbite assessment of two

crowns on the maxillary central
incisors
Fig. 13 The Bucco-

lingual thickness is
measured at the
junction of the middle
third and incisal third Fig. 14 The Golden proportion relates to the mesio-distal
of a tooth (depicted by widths of the central and lateral incisors and the mesial
the green line) aspect of the canine

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PRACTICE
evident and variations are often apparent. In one Secondly, the right and left sides of the max-
study, measurements of plaster casts of natural illary sextant should be balanced. If the right lat-
teeth revealed that only 17% conformed to the eral incisor is lingually inclined or rotated in
Golden proportion.12 This begs the question that relation to the arch, the contralateral lateral
if only some teeth conform to this rule, which should show a similar misalignment to create a
ratio is prevalent for the rest of the population? balanced look (Figs 18-20). An example of the
Although the Golden proportion is invaluable as latter scenario is evident in patients with Angle’s
a starting point for aesthetic appraisal, the reali- Class II, division II occlusion (Fig. 21).
ty is that any ratio from 0.6 to 0.8 is aesthetically
acceptable. The salient points to consider are
harmony, balance, morphopsychology, and psy-
chology.
Firstly, to create harmony the chosen ratio
should be repeated moving distally from the cen-
tral, to lateral incisors, to the canines.
Harmony relies on similar repeated proportions,
rather than the actual size of the elements (Figs
15-17). For example, if an individual has a large Fig. 18 Balance: lingually inclined right
lateral incisor with a similar
nose, small eyes and thin lips, the face will lack contralateral misalignment
harmony because the nose will predominate. (facial view)
However, large eyes, full lips, and a large nose
will blend harmoniously with the rest of the face.
Fig. 19 Balance: lingually inclined right

lateral incisor with a similar
contralateral misalignment (occlusal
view)
Fig. 15 Harmony: narrow repeated proportions of

anterior maxillary sextant (0.6 w/l ratio – small)
Fig. 20 Balance: mesio-buccal

rotations of the right and left lateral
incisors
Fig. 16 Harmony: ‘ideal’ repeated proportions of

anterior maxillary sextant (0.75 w/l ratio)
Fig. 21 In an Angle’s Class II, division II

occlusion, the mesial aspect of the
lateral incisor facially overlaps the
distal aspect of the central incisor
Lastly, morphopsychological and psychologi-

cal factors can influence the chosen ratio for the
tooth-to-tooth relationship. For example, if the
intention is to convey masculinity by choosing a
larger recurring ratio in a small arch, a disto-facial
imbrication of one or more teeth in the maxillary
Fig. 17 Harmony: wide repeated proportions of anterior anterior segment resolves the predicament. Con-
maxillary sextant (> 0.8 w/l ratio) versely, a mesio-facial imbrication conveys

3p135-141.qxd 18/07/2005 11:46 Page 140
PRACTICE
femininity with a narrow maxillary arch form. To erality, pronounced embrasures convey youth-
summarise, the paramount issue for gaining fulness and femininity, while shortened, worn
aesthetic approval in a composition is ensuring edges convey ageing and masculinity (Fig. 24).
harmony and balance, irrespective of size or ratio. The clinician should be guided by patient pref-
Another aesthetic marker is the axial inclina- erences, age and gender before prescribing
tion of the upper anterior teeth. Ideally, a mesial precise incisal embrasure angles for artificial
axial inclination seems to attract aesthetic restorations.
approval, while a distal one conveys visual ten-
sion. One explanation why a mesial inclination,
as opposed to distal one, invokes a sense of aes-
thetic approval (Fig. 22) is that the curvature of
an object (convex or concave) is important to
the way it is perceived. Concavity conveys
receptiveness and belonging, while convexity
the opposite, eg pushiness and aggression. An
example is a relaxed smile when the concavity
of the maxillary incisal plane is parallel to the
concavity of the mandibular lip. Both these
concavities are perceived as welcoming and
receptive, which after all, is the purpose of a
smile. In a similar manner, mesial axial inclina- Fig. 24 Blunt, worn incisal embrasures, with constant
anterio-posterior angles
tion forms a concave curvature, also conveying
receptiveness and belonging. Further enrich-
ment of the anterior dental segment is created INTER-ARCH RELATIONSHIP
by ensuring that the interproximal contact Horizontal and vertical overbite depends on the
points coincide with the incisal edges, and the inciso-gingival length of the anterior teeth
curvature of the mandibular lip, enhancing the (both maxillary and mandibular), the shape of
cohesiveness of the dentofacial composition. the arches, and angulations of the teeth in the
Incisal embrasures have a distinct appear- sagittal plane. In ideal circumstances, the max-
ance depending on age and sex. For virgin illary central incisors are 12 mm long, perfectly
teeth, soon after eruption, the embrasure angle aligned and the arch form is within the norm,
increases anterior-posteriorly from the maxil- with the mandibular central incisor 10 mm
lary incisors to the canines (Fig. 23). As a gen- long. In this case, the vertical overlap and hori-
zontal overlap are 4 mm and 2 mm, respectively.
Furthermore, with this ideal overbite and over-
jet, the occlusal vertical dimension (OVD) is 18
mm, measured from the gingival zeniths of the
maxillary and mandibular central incisor.
Once again, these utopian clinical presenta-
tions are rare. To establish a correct inter-arch
relationship, the starting point is the location of
the maxillary central incisor edge position with
the lips at rest, and during a relaxed smile (Figs
25 and 26).
During these two soft tissue positions, the
incisal edges are assessed, and influenced by
three variables. The first is aesthetics. Ideally,
the maxillary incisal edges should be parallel to
the curvature of the mandibular lip. The second
issue is to ensure that phonetics are not com-
promised. In the sagittal plane, when the ‘f’ and
‘v’ sounds are spoken, the buccal surfaces of the
maxillary incisors should contact the inner or
mucosal surface of the mandibular lip (Fig. 27).
Fig. 22 A mesial axial convergence
of the anterior teeth is conducive for
If these teeth encroach on the cutaneous part of
aesthetic approval the mandibular lip, this indicates either an over-
contoured, or bulbous restoration or incorrect
tooth angulations. Lack of contact with the
lower lip indicates shortened or incorrectly
aligned maxillary incisors. The ‘s’ sound deter-
mines the vertical dimension of speech, charac-
terised by an unimpeded edge-to-edge position
of the maxillary and mandibular incisors. Finally,
Fig. 23 Sharp, well-defined incisal during a ‘th’ sound, the tongue should make
embrasures, with increasing contact with the palatal surfaces of the maxil-
anterio-posterior angles lary incisors.

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PRACTICE
Fig. 25 Assessment of incisal tooth exposure with the Fig. 27 Correct phonetics and incisal inclination: during
lips at rest ‘f’ and ‘v’ sounds of speech, the buccal surfaces of the
maxillary central incisors touch the inner, or mucosal,
surface of the mandibular lip
ceramist ultimately rely on their experience

and observations, combined with patients’
desires, for creating functioning and aestheti-
cally pleasing prostheses.
1. Williams J L. A new classification of human tooth forms with

a special reference to a new system of artificial teeth. Dent
Cosmos. 1914; 56: 627.
2. WJ, Murchison D F, Broome J C. Esthetics: Patient perception
of dental attractiveness. J Prosthodont 1996; 5: 166-171
3. MacArthur D R. Are anterior replacement teeth too small? J
Fig. 26 Assessment of incisal tooth exposure during a Prosthet Dent, 1987; 57: 462–465.
relaxed smile 4. Housemm, Loop J L. Forum and colour harmony in Dental
Art. Whittier, Calf: mm House, 1939.
The third determinant of the incisal edge 5. Marquad S. Esthetic facial analysis. 30th Annual USC
Periodontal and Implant Symposium, Los Angeles, California,
position is the anterior guidance, often ignored January 21-23, 2005.
at the expense of aesthetics, resulting in ultimate 6. Rufenacht C R. Fundamental of esthetics Quintessence
failure of restorations due to unwanted protru- Publishing Co. Inc., Chicago, II, 1990; 4: 114.
7. Chiche, G J and Pinault A E Fundamental of esthetics of
sive interferences. anterior fixed prosthodontics. Quintessence Pub Co.Inc.,
1994; 3: 59.
CONCLUSION 8. Sulikowski A, Yoshida A. Three dimensional management of
The teeth, as with the other perspectives of den- dental proportion: A new esthetic principle – ‘The Frame of
Reference’ . QDT 2002; 25: 8-20.
tal aesthetics, display variance and nuances, 9. Lombardi R E. The principles of visual perception and their
showing individuality in a given dentition. This clinica; application to dental esethetics. J Prosthet Dent,
article has tried to present old and new con- 1973; 29: 358–381.
10. Levin E l. Dental aethetics and the golden proportion. J
cepts on tooth morphology, size and their rela- Prosthet Dent, 1978; 40: 244–252.
tion to each other. In conclusion, no single 11 Woelfel J B. Dental Anatomy: Its relevance to Dentistry, ed 4.
aspect can be accredited with successfully Philadelphia: Lea and Febiger, 1990.
12. Ward D H. Proportional smile design using the recurring
arriving at the final shape and dimensions of esthetic (RED) proportion. Dent Clin North Am, 2001; 45:
the maxillary anterior teeth. The clinician and 143–154.

4p195-202.qxd 05/08/2005 11:07 Page 195
5
IN BRIEF
• Gingival topography correlates with support from the teeth and underlying bone
architecture.
• Assessing periodontal biotype and bioform is a prerequisite for prosthodontic and implant
treatment planning.
• A classification of gingival progression of the anterior maxillary sextant is elementary for
creating optimal ‘pink aesthetics’.
VERIFIABLE
CPD PAPER

Gingival perspective
I. Ahmad1
INTRODUCTION ANATOMY OF THE DENTOGINGIVAL COMPLEX

The gingival perspective is concerned with the soft In cross section, the dentogingival complex is
ANTERIOR DENTAL tissue envelope surrounding the teeth. The gingi- composed of three entities: the supra-crestal con-
AESTHETICS
val texture, shape, tooth-to-tooth progression and nective tissue attachment, epithelial (or junctional
1. Historical perspective its relation to the extra-oral tissues is interdepen- epithelium) attachment and the sulcus (Fig. 1).
2. Facial perspective dent on many factors. These include anatomy of The connective tissue fibres emanate from the
3. Dento-facial perspective the dentogingival complex, tissue hierarchy, osseous crest to the cemento-enamel junction
4. Dental perspective osseous crest considerations, periodontal biotype (CEJ), the epithelial attachment from the CEJ onto
5. Gingival perspective and bioform, tooth morphology, contact points, the tooth enamel, and coronal to the latter is the
6. Psychological perspective* tooth position (gingival progression), and extra- gingival sulcus or crevice. The landmark research
oral skeletal and soft tissue landmarks. The aim of by Garguilo1 and Ingber2 established the ubiqui-
this section on anterior dental aesthetics is to dis- tously quoted biologic width, calculated by addi-
* Part 6 available in the BDJ book cuss these variables, citing physiological norms, tion of the linear measurement of the connective
of this series
and clinical protocols to assess and rectify abnor- tissue and epithelial attachment, and quoted as
malities for a specific treatment modality. 2.04 mm. The connective tissue and epithelial
Sulcus
0.69mm
Epithelial attachment
0.97mm
Biological
Width
CEJ
2.04mm Connective tissue
attachment
1.07 mm
Tel: +44 (0)20 8861 3535, Fax: +44 (0)20
Fig. 1 Sagittal
Refereed Paper cross section
doi: 10.1038/sj.bdj.4812611 of the
© British Dental Journal 2005; 199: dentogingival
195–202 complex

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PRACTICE
attachments have been shown to be the most con-

sistent, while the sulcus depth varies enormously,
depending on type of tooth, site of the tooth, pres-
ence or absence of adjacent teeth, diastemae,
periodontal disease and passive or altered passive
eruption. The significance of the biologic ‘width’
is its presence around every tooth. It is also worth
noting that the biologic ‘width’ is actually a three-
dimensional concept, not limited to a single linear
plane, and the term ‘biologic space’ has been pro-
posed to encompass this three-dimensional form.
Fig. 3 Highly stippled texture of the attached gingivae
In effect, this natural barrier, or shield protects the
two most vulnerable structures of a tooth; the
periodontal ligament and alveolar bone, which
ultimately determines the survival and longevity
of the dental elements. Of course, a shield is most
effective when intact, if violated by bacteria or
iatrogenic insult, its function is severely compro-
mised, which jeopardises the teeth causing a
precarious outcome. For example, infestation
by pathogens is a precursor to periodontal dis-
ease, while violation by restorative procedures,
including surgery or crown preparation stages,
mitigates the efficacy of this buffer zone. Fig. 4 Smooth texture of the attached gingivae
From the facial view, a healthy periodontium
has the following demarcations. Starting apical-
ly, the loose mucosa terminates at the mucogin-
gival junction. From this point coronally, the tis-
sue is keratinised and divided into the attached
gingivae, which terminates as the free gingival
margin (FGM) (Fig. 2). The texture of the kera-
tinised gingivae can be highly stippled or
smooth (Figs 3 and 4), or have intermediate tex-
tures between these two extremes. In certain
cases, there is a distinct elevation of the FGM
called the gingival groove (Fig. 5), while individ-
Fig. 5 Elevation of the FGM resulting in the so-called
uals with dark complexion often have melanin gingival groove
pigmentation of the attached gingivae (Fig. 6).
TISSUE HIERARCHY
To appreciate the following discussion, it is
important to consider tissue hierarchy, or com-
mand structure, of the dentogingival complex.
Fig. 2 Facial view of the Fig. 6 Physiological pigmentation of the attached

dentogingival complex showing the gingivae of a dark skinned individual
mucosa, mucogingival junction,
attached gingivae and the free
gingival margin (FGM) between natural teeth. If the hierarchy was
reversed, the interproximal osseous crest
The protagonists are the teeth, which in turn would peak 3 mm from the incisal edge
influence the contour of the soft tissue and (assuming a normal osseous bone pattern),
underlying osseous architecture. and the soft tissue would cover the latter, cre-
Embryologically, the bone and soft tissues ating an interdental papilla, terminating at the
develop first, and lastly the teeth erupt into incisal edges between the teeth. Clearly, this is
the oral cavity through the bone/soft tissue not the case. It is the diastema between the
envelope. Because of this sequence, it is falla- teeth that determines the soft tissue level,
cious to assume that the hierarchy is concur- which terminates apically and the underlying
rent with the chronological development of bone positions itself accordingly. Another
the three tissues comprising the dentogingival example is the distance from the contact point
unit. For example, consider a diastema to the interproximal osseous crest. If the dis-

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crepancy between the contact point and

osseous peak is greater than 5 mm, there is
incomplete papilla fill. However, if this dis-
tance is 5 mm or less, a papilla completely fills
the interproximal void, but the interproximal
bone does not take a position 3 mm from the
most coronal aspect of the papilla. This again
emphasises the dictum that the teeth are the
protagonists, followed by the soft tissue and
bone topography (Figs 7 and 8).
Fig. 9 Preoperative defective porcelain fused to Fig. 10 Removal of offending crown, revealing
OSSEOUS CREST metal crown on maxillary left lateral incisor an intra-radicular cast post and core
Fig. 7 Maxillary median diastema lacking an

interproximal papilla
Fig. 11 Intra-crevicular placement of retraction Fig. 12 Adopting a haemorrhage free clinical
cord to protect the biological width during protocol to refine and shape the metal core and
crown preparation tooth margins
than 1 mm, creating a perilous threat to biologi-

cal width violation by restorative procedures
such as crown preparation and subgingival
crown margin location.
PERIODONTAL BIOTYPE AND BIOFORM

The human tissue biotype is classified as thin,
normal or thick (Figs 13 and 14).3,4 The thin peri-
Fig. 8 Same patient as Fig. 8 following the provision of odontal biotypes are friable, escalating the risk
two all-ceramic crowns for the maxillary central incisors. of recession following crown preparation and
The contact point created between the crowns is now periodontal or implant surgery. This is particu-
less than 5 mm from the interproximal osseous crest,
allowing the formation of an interdental papilla larly significant for full coverage crowns for the
following reasons. Firstly, the thin gingival mar-
gins allow visibility of a metal substructure
The quoted measurement of 2.04 mm for the (either porcelain fused to a metal crown or
biologic width assumes that the osseous crest is implant abutment), thereby compromising aes-
normal, prevalent in 85% of the population,
with a sulcus depth of 1 mm, yielding 3 mm for
the entire dentogingival complex. The impor-
tance of the latter is that if crowns are neces-
sary, meticulous care should be taken to ensure
that this equilibrium is maintained (3 mm), and
not violated by any clinical procedure (Figs 9-
12). For implant placement, a different protocol
is adopted. If the preoperative dentogingival
complex is normal (3 mm), and the tooth
requires extraction and subsequent implant Fig. 13 Thin periodontal biotype
replacement, it becomes necessary to employ
orthodontic extrusion to compensate for post
surgical recession (2-3 mm). In 13% of individ-
uals, the osseous crest is low, and the sulcus
measurement exceeds the 1 mm norm, varying
from 2-4 mm mid-facially and greater than 4
mm interproximally. In these cases, the deep
gingival crevice is particularly delicate and sus-
ceptible to surgical manipulation and ensuing
recession. On the other hand, in 2% of patients,
the bone crest is high, with a sulcus depth of less Fig. 14 Thick periodontal biotype

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thetics in the anterior regions of the mouth. In bone is wider, but the disparity between the bone
these circumstances, all-ceramic crowns, or contour and the FGM is problematic for
ceramic implant abutments are a prerequisite to favourable aesthetics (due to possible recession
avoid aesthetic reproval. Secondly, due to the and creation of ‘lack triangles’) following
fragility of the thin tissue, delicate management implant or restorative procedures.5
is essential for avoiding recession and hence
visibility of subgingivally placed crown margins TOOTH MORPHOLOGY
at the restoration/tooth interface. Conversely, a Tooth morphology determines two aspects of
thick biotype is fibrotic and resilient, making it gingival undulations. Firstly, the basic tooth
resistant to surgical procedures with a tendency forms: circular, square or triangular, determine
for pocket formation (as opposed to recession). the degree of gingival scallop. Circular (oval) or
Therefore, a thick biotype is more conducive for square teeth produce a shallower gingival scal-
implant placement, resulting in favourable aes- lop, while triangular teeth form the opposite, a
thetic outcomes. pronounced scallop. The latter predisposes to the
Periodontal bioforms are categorised into so-called ‘black triangles’; especially with a thin
three basic gingival scallop morphologies, high, biotype which has a propensity for recession.
normal and flat (Figs 15–17). While the facial Furthermore, triangular teeth have divergent
and lingual gingival scallop mimics the underly- roots with thicker interproximal bone, resulting
ing bone architecture, this is not always the case in reduced vertical bone loss compared with
interproximally. The norm is a discrepancy of square teeth, whose root proximity and thinner
4 mm between the interproximal gingival peaks interdental bone have a higher incidence of ver-
(most coronal) and the mid-facial free gingival tical bone resorption. However, squarer teeth
margin peaks (most apical). When this discrep- yield better interproximal papilla maintenance
ancy is less than 4 mm, a flat scallop is evident, due to a smaller interproximal distance from the
while a greater than 4 mm discrepancy results in osseous crest to the FGM.
an exaggerated or high scallop. With a shallow Secondly, the convex acuity of a tooth circum-
scallop, the interproximal bone is thin, and the
interproximal gingival contour nearly parallel to
the underlying bone contour. The latter is
advantageous for implant therapy since the
bone has a congruous relationship with the FGM
and is less prone to post-surgical recession. With
a pronounced or high scallop, the interproximal
Fig. 18 The convex acuity of tooth topography

determines the position of the FGM. The gingival zenith
on the left central incisor is apical and distal to the long
axis of the tooth (normal). However, the concave facial
profile of the right central incisor has resulted in a
coronal mid-facial creep of the FGM
Fig. 15 High scallop periodontal
bioform
ference influences the coronal/apical position of
the FGM. Put succinctly, convex tooth morpholo-
gy yields a more apical location of the FGM, while
a concave shape leads to a coronal position of the
FGM (Fig. 18). This is blatantly evident in the gin-
gival zeniths of the maxillary anterior teeth. For a
central incisor, the most convex part facially is
distal to the long axis of the tooth, with the FGM
Fig. 16 Normal scallop periodontal zenith occupying a similar location. For a lateral
bioform (the maxillary central incisor, the maximum convexity is in line with
incisors have acrylic temporary the long axis of the tooth, with the gingival zenith
crowns)
positioned accordingly. The canine has a similar
maximum convexity to the central incisor, and
its gingival zenith is distal to the long axis of
the tooth (Fig. 19). Often, poor dentistry conceals
these zeniths (Fig. 20), which are readily regained
by replacing the offending restoration. The bio-
logical relationship of tooth morphology to FGM
locations can be exploited to manipulate the soft
tissue around prostheses that are aesthetically
sensitive. A flat or slightly concave topography of
Fig. 17 Low or flat scallop an artificial prosthesis encourages a more coronal
periodontal bioform location of the FGM, while the opposite is true for

4p195-202.qxd 05/08/2005 11:15 Page 199
PRACTICE
of teeth. No teeth, no papillae; a scenario, which

is evident in edentulous ridges where papillae are
absent. For example, if a lateral incisor is extract-
ed, the interproximal papilla between the central
incisor and canine will disappear, and the FGM of
the lateral incisor will re-establish itself to 3 mm
from the underlying osseous crest. This is identi-
cal to the unsupported dentogingival complex on
the mid-facial aspect of natural teeth.8 The latter
is also true for diastemae, where an interdental
papilla is absent (Figs 7 and 8). Numerous tech-
Fig. 19 The gingival zeniths of the maxillary anterior niques for preserving9 and restoring10 the inter-
teeth. For the central incisor, the apical peak of the FGM
is distal to the long axis of tooth, for the lateral in line dental papilla have been described and the
with long axis of the tooth, and for the canine distal to prosthodontist should strive to fill open gingival
long axis of the tooth embrasures to create optimal ‘pink aesthetics’.
Furthermore, the degree of interproximal fill is
also dependant on the periodontal biotype. A
thick periodontal biotype encourages interdental
fill, while a thinner tissue type creates un-aesthet-
ic hollow gingival embrasures. This problem is
compounded when an implant is placed next to a
natural tooth. It is the interproximal bone of the
adjacent natural tooth that determines the pres-
ence, or absence of a papilla, not the bone sur-
rounding the implant fixture. For thick biotypes,
the papilla may be established to normal dimen-
sions of 5 mm, but for thin biotypes, it is difficult
Fig. 20 Defective crown on right central incisor creating to recreate a papilla longer than 4 mm from the
an amorphous gingival margin, compared to the left osseous crest.11 Finally, the 5 mm rule is only
natural central whose gingival zenith is distal to the long
applicable for adjacent natural teeth or implants
axis of the tooth
bounded by natural dentition. Due to the flat fix-
ture platforms, adjacent implants lack the inter-
a convex surface topography, resulting in a more proximal osseous peak present between natural
apical position of the FGM.6 teeth.12 The recently introduced scalloped plat-
form fixtures (Nobel Perfect, Nobel Biocare, Swe-
CONTACT POINTS den), may help to redress this issue with an
The contact points of the maxillary teeth are rele- endeavour to mimic natural root morphology.
vant for ensuring optimal ‘pink aesthetics’ for
patients with a high smile line (or visible cervical TOOTH POSITION AND GINGIVAL
margins). The iconic study by Tarnow,7 which PROGRESSION
produced the ‘5 mm rule’, states that when the The intra-arch tooth position is assessed in three
distance from the contact point to the interproxi- planes: vertical (apical-coronal), sagittal (facial-
mal osseous crest is 5 mm or less, there is com- lingual) and horizontal (mesial-distal). In the
plete fill of the gingival embrasures with an vertical plane, the cervical portion of the tooth
interdental papilla. For every 1 mm above 5 mm, can be apical, coronal or in line with the FGM.
the chance of complete fill is progressively An example of a coronally positioned FGM
reduced by 50%. For square-shaped teeth with occurs in cases of altered passive eruption,
wide contact points, the chances of ‘black trian- where the FGM fails to migrate apically to
gles’ is minimal compared with triangular teeth assume its relative position to the CEJ (Fig. 22).
having narrow, more incisally positioned contact The latter position is misleading when placing
points (Fig. 21). The existence of the interdental crown margins subgingivally. If this gingival
papilla is dependent on the presence or absence anomaly is ignored, following crown cementa-
Fig. 21 Defective crown on maxillary left lateral incisor Fig. 22 Altered passive eruption on the maxillary right
with open gingival embrasures forming the so-called lateral incisor
‘black triangles’

4p195-202.qxd 05/08/2005 11:15 Page 200
PRACTICE
tion, the FGM may recede apically, exposing the

GAL Angle
crown/tooth interface and compromising aes- (GA)
thetics. In the sagittal plane, a facially placed
tooth will have an apically located FGM with a GINGIVAL AESTHETIC LINE (GAL)
thin underlying buccal plate (Fig. 23). In these
circumstances, the thin bone contradicts ortho-
dontic repositioning and bone and/or soft tissue
grafting may be the only option for rectifying
soft tissue contours. Conversely, a lingually
placed tooth will reveal a coronally placed FGM,
similar to that of altered passive eruption. Final-
ly, imbrications in the horizontal plane result in Maxillary
crowding, due to limited arch space for wide Dental Midline
teeth (Fig. 24). These teeth have close root prox-
imity with thin interproximal bone. Orthodontic Fig. 25 GAL classification
movement is an option for paralleling roots and
creating a more favourable interproximal bone
support for the overlying gingival architecture. >45° GA <90°
The opposite is the case for diastemae with thick
interproximal bone and blunted papillae. The GAL
latter clinical manifestations should be borne in
mind when restorative or surgical procedures are
undertaken, with a view to predicting the ensu-
ing post treatment gingival levels.
One of the most significant features of gingi-
Maxillary
GAL CLASS I Dental Midline
Fig. 26 GAL Class I

Fig. 23 Bucally placed maxillary
left lateral incisor with an apical
FGM and thin underlying buccal
osseous plate (compare to right >45° GA <90°
lateral incisor)
GAL
Maxillary
Fig. 24 Severe crowding of the GAL CLASS II Dental Midline
maxillary anterior sextant
val aesthetics is contour progression from the Fig. 27 GAL Class II

incisors to canine. The gingival aesthetic line
(GAL) is a classification for creating pleasing
gingival level transition between the maxillary GA = 90°
anterior teeth. GAL is defined as a line joining
the tangents of the zeniths of the FGMs of the
GAL
central incisor and canine. The GAL angle is that
formed at the intersection of this line to the
maxillary dental midline (Fig. 25). Assuming a
normal w/l ratio, anatomy, position and align-
ment of the anterior dental segment, four classes
of GAL are described:
Class I: The GAL angle is between 45º and 90º
and the lateral incisor is touching or below (1- Maxillary
2 mm) the GAL — (Fig. 26) GAL CLASS III Dental Midline
Class II: The GAL angle is between 45º and 90º
but the lateral incisor is above (1-2 mm) the
GAL and its mesial part overlaps the distal Fig. 28 GAL Class III

4p195-202.qxd 05/08/2005 11:17 Page 201
PRACTICE
aspect of the central incisor. This situation is

often seen in Angle’s Class II or pseudo-Class
II conditions, and adds variety to the dental
composition — (Fig. 27)
Class III: The GAL angle = 90º, and the canine,
lateral and central incisors all lie below the
GAL — (Fig. 28)
Class IV: The gingival contour cannot be
assigned to any of the above three classes —
(Fig. 29). The GAL angle can be acute or Fig. 32 The right maxillary
quadrant shows a GAL Class I,
obtuse. A myriad gingival asymmetries are while the left quadrant a GAL
apparent clinically including: recession, pas- Class II
sive and altered passive eruption, eccentric
eruption patterns, loss of interdental papillae, EXTRA-ORAL ANATOMY
clefts and high frenal insertions. Extra-oral anatomy is genetically determined,
In a single mouth, the right and left sides can consisting of the skeletal and soft tissue land-
marks. The perio-oral skeletal and soft tissue form
of the lower third of the face should harmonise
with the dentition. The latter is elaborated in part
2 (facial perspectives) and part 3 (dentofacial per-
spectives) of this series.
During a relaxed ‘ideal smile’, the upper lip
exposes the cervical aspects of the maxillary
anterior teeth. The gingival margins of the max-
illary central incisors should be symmetrical and
at the same height. Up to 3 mm of gingival
exposure above the cervical margins of the max-
illary teeth is aesthetically acceptable (Fig. 33).13
Beyond 3 mm results in a ‘gummy’ smile, requir-
Fig. 29 Erratic gingival progression from central incisor ing correction by orthodontic or surgical inter-
to canine, resulting in a GAL Class IV vention to avoid visual tension (Fig. 34). Treat-
ment modalities depend on the type of pathosis,
display different GAL classes (Figs 30–32). The eg hyperplastic gingivae require gingivectomy
aim of the clinician is to restore the gingival or crown lengthening; recession can be correct-
contour to a GAL Class I, II or III to achieve aes- ed using orthodontics or cosmetic periodontal
thetic appraisal. plastic surgery using tissue grafts or guided tis-
sue regeneration membranes; over eruption by
orthodontic intrusion; deficient pontic sites by
ridge augmentation procedures and skeletal
abnormalities by orthognathic surgery.
Fig. 33 Up to 3 mm, gingival

exposure (white line) during a
smile is not detrimental for
Fig. 30 Right lateral view of maxillary anterior teeth
aesthetic approval. The incisal
showing a GAL Class III
plane (lime green line) should
coincide with the white gingival
exposure line
Fig. 34 Excessive gingival

Fig. 31 Left lateral view of maxillary anterior teeth for exposure results in an un-
same patient in Fig. 30, with a GAL Class II aesthetic ‘gummy smile’

4p195-202.qxd 05/08/2005 11:17 Page 202
PRACTICE
CONCLUSION 4. Sanavi F, Weisgold A S, Rose L F. Biologic width and its

relation to periodontal biotypes. J Esthet Dent 1998; 10:
Unlike other topics covered in this anterior aes- 157-163.
thetic series (facial, dentofacial or dental), the 5. Kois J C. Altering gingival levels: The restorative
gingival perspective is the most quantifiable, and connection – Part 1: Biological variables. J Esthet Dent
least prone to artistic interpretation. However, 1994; 6: 3-9.
6. Smukler H, Castellucci F, Capri D. The role of implant
failing to take account of the soft tissue consider- housing in obtaining aesthetics: Part 2. Customising the
ations will negate all the other aspects of treat- peri-implant soft tissues. Pract Proced Aesthet Dent 2003;
ment, resulting in ultimate aesthetic failure. Cor- 15: 487-490.
recting gingival anomalies after completing 7. Tarnow D, Magner A, Fletcher P. The effect of the distance
from the contact point to the crest of bone in the presence or
aesthetic rejuvenation is costly, embarrassing absence of the interproximal dental papilla. J Periodontol
and frustrating for the entire dental team. Rather 1992; 63: 995-996.
than an afterthought, the gingival viewpoint, at 8. Spear F. Maintenance of the interdental papilla following
anterior tooth removal. Pract Periodont Aesthet Dent 1999;
the outset, should be an integral part of any aes- 11: 21-8.
thetic treatment planning, ensuring health, 9. Beagle J R. Surgical reconstruction of the interdental papilla:
approval and longevity of the final result. case report. Int J Perio & Rest Dent 1992; 12: 145-151.
10. Lie T. Periodontal surgery for the maxillary anterior area. Int J
1. Garguilo A W, Wentz F M, Orban B. Dimensions and relations Perio & Rest Dent 1992; 12: 73-82.
of the dentogingival junction in humans. J Periodontol 1961; 11. Jemt T. Regeneration of gingival papilla after single-
32: 321. implant treatment. Int J Periodont Rest Dent 1997; 17:
2. Ingber J S, Rose L F, Caslet J G. The biological width – a 327-333.
concept in periodontics and restorative dentistry. Alpha 12. Tranow D, Chu S C, Wallace S S. The effect of inter-implant
Omegan 1977; 70: 62-65. distance on the height of inter-implant bone crest. J
3. Seibet J, Lindhe J. Esthetics and periodontal therapy. In Lindh Periodontol 2000; 71: 546-549.
J, ed. Textbook of clinical periodontology. pp 431-467. 13. Allen P. Use of mucogingival surgical procedures to enhance
Copenhagen: Munksgaard, 1989. aesthetics. Dent Clin North Am 1988; 32: 307.

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12p737-742.

qxd 01/06/2005 15:01 Page 737

Anterior dental aesthetics: Historical perspective

INTRODUCTION interdependent and interrelated. However, for

1BDS, The Ridgeway Dental Surgery, 173

BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005 737

Fig. 3 Dental perspective

Fig. 5 Basic shape: Triangle

Fig. 4 Gingival perspective

detailed analysis of the relationship between

738 BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005

Fig. 8 Imaginary anterio-posterior line of the incisal

Ancient Greeks were preoccupied with

BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005 739

Fig. 12 Anterior view of teeth in centric occlusion

740 BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005

another method exploited for creating domi-

THE GESTALT PRINCIPLE

Incorporating the above entities in a compo-

Proximity facilitates association, linking,

Continuity ensures progression, e.g. recurring or

Closure assures cohesiveness, such as a frame or

Closure is particularly important for our

BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005 741

extremely important for mental stability by

1. Hegel G W F. Philosophy of History. New York: Collier, 1905.

742 BRITISH DENTAL JOURNAL VOLUME 198 NO. 12 JUNE 25 2005

Anterior dental aesthetics:

INTRODUCTION professionals. The optical illusion of a white

BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005 15

categories are subjective evaluations based on

16 BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005

MORPHOPSYCHOLOGY • Facial typology

The form of teeth should conform to these

Fig. 7 Facial typology: sanguine personality

Fig. 10 Frontal view of

Fig. 8 Facial typology: nervous personality

Fig. 11 Sagittal view

BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005 17

18 BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005

shows numerous, ingenious criteria for dental

These parallel lines create horizontal symme-

BRITISH DENTAL JOURNAL VOLUME 198 NO. 1 JULY 9 2005 19

differences between the functional and aesthet-

Fig. 23 Post-operative status showing coincidence

From the sagittal aspect, the horizontal lines

Fig. 24 Horizontal facial lines viewed from sagittal

The nasolabial angle is the intersection of

20 BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005

<90°, the maxilla is prominent and a convex

BRITISH DENTAL JOURNAL VOLUME 199 NO. 1 JULY 9 2005 21

Anterior dental aesthetics:

INTRODUCTION the lips in relation to the anterior maxillary sex-

* Part 6 available in the BDJ book

1BDS, The Ridgeway Dental Surgery, 173

BRITISH DENTAL JOURNAL VOLUME 199 NO. 2 JULY 23 2005 81

STATIC The length of the upper lip varies from 10-

82 BRITISH DENTAL JOURNAL VOLUME 199 NO. 2 JULY 23 2005

THE DYNAMIC POSITION