E S T H E T I C D E N T I S T R Y
E sthetics and the
edentulous patient
G eorge A . M urrell, D D S
M o st individuals undergo some degree o f
psychological shock, depression, and loss o f
self-esteem after the loss o f their teeth.
Optimum success in the treatment o f the
edentulous patient can no longer be lim ited
to the proper fit, function, speech, selection,
and arrangement o f teeth. In addition,
to d a y’s dentists must use treatment strate­
gies th at include p ro p e r psych ological
management, caring, and recognition o f the
importance o f the patien t’s perception o f
what is personally esthetic. This article
addresses the esthetic considerations o f this
restorative challenge.
ll too frequently, when examining an
A edentulous patient, the clinician finds
the complete dentures technically satisfac­
tory, but the patient is dissatisfied. Patients’
concerns may be unclear or exaggerated;
often, their functional and esthetic demands
are beyond the limits of reality. The dentist
may have remade the dentures several times
but the patient is still not satisfied.
M any dentists have succeeded in the
technologies of denture fabrication, but
have failed to address the psychological
needs of the patient.1 3 A better understand­
ing of patient needs begins with recognizing
the im portance the face, mouth, and teeth
have in personality developm ent, self­
esteem, attitudes, and social and business
success.
Teeth physically support the lower part
of the face, and have a m ajor role in such
basic functions as eating, speaking, smiling,
and personal relationships. W hen teeth are
lost, esthetics and function relating to these
activities are lost or compromised. There
is a self-perception of aging and loss of
health and fitness. W hen teeth are lost,
individuals often experience a psychologi­
cally traum atic shock. Some persons learn
to accept their loss, while others do not and,
as a result, may rem ain in a state of grief
or depression indefinitely (L. Pilling, MD,
personal com munication, 1987).
Regardless of how well the dentist selects
and esthetically positions the components
of a prosthetic device, a disturbed patient,
even with a technically correct denture may
not be satisfied. He or she may function
poorly, respond negatively, act disagree­
ably, and thus appear esthetically unattrac­
tive. Unless the dentist recognizes and treats
the psychological, as well as the technolog­
ical aspects of the edentulous p atien t’s
denture problem, a successful, esthetically
pleasing complete restoration cannot be
achieved. This article illustrates the role that
esthetic dentistry has in the successful
treatm ent of the edentulous patient.
H istorical perspective
Williams4 is generally credited with found­
ing the present-day concepts of square,
tapering, and ovoid tooth forms as they
relate to face form in determining harm o­
nious teeth for the patient’s complete denture.
He began his research on the classification
of anterior hum an teeth in 1909. Before that
time, tooth form was believed to be related
to tem peram ent, which was classified as
nervous, sanguine, bilious, and lymphatic.4
Williams published his work in 1914,5 and
even though he dem onstrated conclusively
th a t th e re was no scien tific evidence
supporting a correlation between tooth
form, face form, or racial background, he
conceded the tooth problem was an art
problem , and th at a to o th form similar to
the patient’s face form should be selected
to avoid disharm ony. Although Williams is
recognized for early esthetic work with
complete dentures, an editorial, entitled
“Aesthetic d en tistry ,” was published 42
years earlier in the 1872 edition of Dental
Cosmos, 6 calling for im proved esthetic
appearance and the application of the laws
of correlation and harm ony with nature,
facial contours, age, and temperam ent: “To
the dentist, the extent of its (the laws of
co rrelatio n ) recognition determ ines his
status as a mere mechanic or an artist. ”
W illiams’s publication initiated an era in
which many researchers expanded this area
o f esthetic dentistry to include the mesio-
d istal and cervicoincisal co n to u rs and
surface texture, the interrelationship of
to o th form , arch form, face form, alignment
form , and harm o n io u s balan ce.7 A fter
refinements were developed in determining
tooth form, size, color, and harm ony,8 a
different concept of selecting and arranging
teeth according to sex, personality, and age
followed.9 This SPA factor, or “dento-
genics” concept,10 was presented in or­
ganized teaching seminars, and contributed
significantly to the progress of the esthetic
appearance of the complete denture. In­
terestingly, it has since been dem onstrated
th a t experts in dental esthetics cannot
accurately differentiate the gender of in­
dividuals when viewing slides showing only
the natural teeth (L. Abrams, and G. Chris­
tensen, personal com m unication, 1985).
A nother significant esthetic contribution
was the m olding of artificial teeth from
impressions of natural teeth, which were
then individually characterized by color.11"
13 D uring this same era, others14-16 dupli­
cated natural gingiva and mucosal contours
JADA (Special Issue) September 1988 ■ 57-E
 E S T H E T I C D E N T I S T R Y

TOOTH DISPLAY

Fig 1-5 ■ Esthetic and functional values controls used

to position anterior denture teeth. Functional values
necessary for prosthetic fabrication can be derived from
setting anterior teeth according to esthetic and phonetic
(functional) controls.

Table 1 . A n te r io r to o th p o s itio n . treatm ent and predict management prob­ occlusal plane, centric relation, and polished
lems were developed on the basis of patient surface coloring and contouring.
C ontrols evaluation, diagnosis, consultation, and This brief historical review shows the
education.29”33 After using these methods, main focus of the esthetic appearance of the
Esthetic Phonetic
dentists were better prepared to anticipate edentulous patient concentrated on tooth
1. Lip support 1. ‘F ’ a n d ‘V’ lip seal problems and assess an optim um course of design. The laws of correlation in the D ental
2. T ooth display 2. ‘S’ position, incisal
treatm ent for the patient. Recently, Curtis Cosmos editorial, “Aesthetic dentistry,”6
edge relationship
3. A natom ical harm ony and coworkers34 described the im portance were no doubt acceptable, but the inclusion
of factors other than tooth design that of tem peram ent may have begun to lose
contribute to the esthetic appearance of popularity in 1909 as it was difficult to apply
and colors. These were then transferred to complete denture esthetics, for example, and was presumed to determine tooth form.
the polished surfaces of the com plete
denture for a natural look and to facilitate
mastication. T ooth arrangem ent was always
considered im portant, from N elson’s arch
form and face form, facial contours and
su p p o rt,17"20 to refinement th a t included
phonetic concerns, tooth display, harmony,
and the functional elements of occlusal
vertical dimension, incisal guidance, and
centric relation.21"25
W ith all these improvements in treating
the esthetic needs of edentulous patients,
still not all dentures are esthetic, functional,
or even satisfactory. Patients differ in their
expectations, dental understanding, and
ability to accept change; dentists differ in
their dental capabilities, artistic sense, and
ability to relate to and manage patients.
Some of these problems were addressed by
Briganti,26 Krajicek,27 and Lom bardi28 in
descriptions of basic art appreciation as
applied to the selecting and arranging of
teeth.
Personality, desires, expectations, m oti­
vations, ability to accept change, willingness
to c o o p e ra te , and self-esteem are all
im portant factors in the course of treatm ent, Fig 6 ■ P o o r lip support, to oth display with previous Fig 7 ■ Im proved lip support, to o th display w ith new
and affect its success. M ethods to determine dentures. dentures.

58-E ■ JADA (Special Issue) September 1988


Fig 8 ■ Im p ro p e r to o th sele c tio n , p o s itio n , an d
arrangem ent o f previous denture.
Fig 9 ■ Im p ro v ed to o th s e le c tio n , p o sitio n , an d
arrangem ent of provisional denture.
As speculated earlier, this may have caused
Williams to begin his search for a better
classification of tooth forms. The refine­
ments that followed were primarily in tooth
design and arrangem ent to achieve a more
natural looking, harm onious prosthesis.
Tem peram ent eventually regained its right­
ful importance but only when it was logically
applied to the areas of patient management
and predicting patient behavioral responses
to prosthodontic treatm ent.
Historically, there has been progress in
treating the esthetic problems of edentulous
p a tie n ts, b u t u n fo rtu n a te ly , available
treatm ent methods for improved esthetic
a p p e a ra n c e o f co m p lete d e n tu re s are
underutilized. Economics, patient desires,
limitations of the denture provider, and
patient physical problem s are a few of the
reasons for the prevalence of inadequate
denture esthetics.
D iscu ssion
Patients’ esthetic desires are often obscure,
confusing, and are frequently based on
emotions or cultural values that are not
clearly understood. Their esthetic concepts
do not necessarily coincide with accepted
principles of art, and can differ with the
E S T H E T I C D E N T I S T R Y
dentist’s suggestions. Esthetics is im portant
to everyone and every person has his or her
own esthetic self-perception. Certain cul­
tu res and ethnic groups have specific
concepts of dental esthetics relating to the
size, shape, and color o f/o r reshaping,
notching, and im planting objects into teeth.
Some edentulous patients’ esthetic desires
may be governed by em otion—wanting
something they never had such as straight
white teeth because their natural teeth were
dark and crooked. Others yearn to recapture
some fragm ent of youth—wishing to have
teeth exactly as they once were; yet, old
photographs often show th at their percep­
tion of their teeth as they once were in youth
bears little resemblance to what is seen in
the picture (L. Weinberg, personal commu­
nication, 1987). The patient’s desire to please
family and friends places the dentist in an
im possible situ atio n , often resulting in
dissatisfaction, denture remakes, or term i­
nation of treatm ent. Anticipation of others’
influence on the patient is critical to success.
W right35 once said, “As an architect of
more than 60 years, I have learned that only
the beautiful is practical. And conversely,
anything that is truly practical, functional,
and useful is beautiful.”
Years ago, P ound33 dem onstrated this
interrelationship in dentistry by showing
how functional values necessary for denture
fabrication could be derived from setting
Fig 10 ■ Im proper tooth selection, arrangem ent, and
anatom ical harm ony affecting facial contours with
previous denture.
Fig 11 ■ Im proved to o th selection, arrangem ent, and
anatom ical harm ony affecting facial contours with new
denture.
Murrell: ESTHETICS AND EDENTULOUS PATIENT ■ 59-E
Fig 12 ■ R ight, im proper contours, to oth position,
a rra n g e m e n t, an d occlusal plane. L eft, im p ro v ed
contours, to o th position, arrangem ent, and occlusal
plane.
anterior teeth according to esthetic and
phonetic (functional) controls (Fig 1-5,
Table 1). In treating the edentulous patient,
impressions are made of the edentulous
m o u th to satisfy th e p ra c tic a litie s o f
com plete denture fit and com fort. The
patient is involved in the proper selection
and arrangem ent of teeth for esthetics. The
teeth are properly positioned in harm onious
occlusion for function. The elements of
p ro sth etic d en tistry —fit, function, and
a p p e a ra n c e — have been tra d itio n a lly
considered separate entities when, in fact,
they are all interrelated. The elements of
denture esthetics and function are insepa­
rable, and are so closely interdependent that
neither can achieve its full potential w ithout
the other.
As the practitioner’s awareness increased,
it became evident th at while setting and
arranging the anterior teeth of the patient
at chairside, an ideal opportunity existed
fo r p sy ch o lo g ical m an ag em en t of th e
edentulous patient. M any patients expe­
riencing this treatm ent recognized that the
dentist was capable, interested, and caring.
D uring these procedures additional time is
also provided for patient involvement and
education. W hen creating the complete
dentures, the dentist can reinforce details
of dental procedures, continuously address
the patient’s desires, work tow ard achieving
them, encourage the patient to feel good
about himself, and discourage any negative
feelings. This often makes patients feel
better ab o u t themselves, and enhances their
self-esteem. The positive result of the total
esthetic restoration of the edentulous patient
establishes a good doctor-patient rapport.
In turn, patients are more cooperative and
understanding of treatm ent trade-offs or
explanations o f why a particular desire
cannot be achieved.
A natural-speaking response is critical to

Fig 13 ■ E xtrem e overclosure o f occlusal vertical
dim ension (O V D ) in denture.
Fig 15 ■ C orrected overclosure o f OVD in denture.
accurately establishing the anterior tooth
position and phonetic function. As the
patient reads w ritten material aloud, the
dentist should observe phonetic quality and
anterior “speaking space.” Evaluation of the
sp e a k in g m o v em en ts ca n be d ifficu lt
because the phonetic response is fleeting and
not always natural. Recently, it has been
found th at by using a video cam era,36 the
patient’s response is more natural, and easier
to evaluate with pause or replay options.
Equally im portant, patients reacted much
more enthusiastically because they could
now see themselves as others do.
The following illustrations demonstrate
clinical examples of certain esthetic prin­
ciples or conditions.
Lip su p p o rt/to o th display. Figures 6 and
7 show improvements in proper lip support
and tooth display.
T o o th s e le c tio n /p o s itio n . This p atient
com plained of denture appearance and buck
teeth that “didn’t look like her” (Fig 8). The
provisional denture (Fig 9) was developed
in her m outh with esthetic and phonetic
controls; the appearance of the denture was
improved so th a t it looked as if it belonged
in her mouth.
A natom ic h arm o n y /to o th selection/facial
contours. These two figures show improve­
ments in anatom ical harm ony. Teeth were
changed from square to ovoid and convex.
60-E ■ JADA (Special Issue) September 1988
E S T H E T I C D E N T I S T R Y
Fig 14 ■ Extrem e overclosure of O VD, facial effect.
Fig 16 ■ C orrected overclosure of OVD facial effect.
Im provement was seen in tooth selection
and position, with a harm onious change in
size, form , m a n d ib u la r a n te rio r to o th
display, improved phonetic ability, and
facial contours (Fig 10, 11).
T o o th p o s itio n /lip s u p p o rt/s m ile lin e /
occlusal plane. Figure 12 shows a dram atic
improvement in anterior tooth selection,
position, display, phonetic ability, smileline,
and occlusal plane. The maxillary denture
pictu red at rig h t in F igure 12 shows
improperly overcontoured polished surfaces
originally created to achieve maxillary lip
support, a poor smileline, and a poor
occlusal plane. The m axillary denture
pictured at left in Figure 12 shows improved
tooth selection, correct lip support achieved
Fig 17 ■ A lveolar contours, buccal space o f a natural
cast necessary for food containm ent and m anipulation.
by proper to o th positioning with the necks
out, and an improved occlusal plane.
V ertic al d im e n s io n /p a tie n t to le ra n c e .
Figures 13 and 14 show overclosure of the
occlusal vertical dimension, and compare
the improved denture appearance and facial
contours after the proper occlusal vertical
dimension was restored (Fig 15, 16). This
patient tolerated his previous denture well,
could eat everything, had no facial discom­
fort, and no denture-related complaints. He
wanted new dentures only because he was
retiring. There were no management prob­
lems with this patient.
Polished surface contours/food m anipula­
tion. The cross-section of a cast of natural
teeth with a straight edge contacting the
maxillary and m andibular alveolar height
of contour simulates the cheek sealing off
the space buccal to the occlusal table for
proper food containm ent and m anipulation
as illustrated by Figure 17. With a slight
tightening of the cheeks, the food in this
buccal space is returned to the chewing
table. If there was no convex alveolar
contour, food would slide into the buccal
folds and under the denture periphery,
which is impossible to remove discretely.
The waxed denture illustrates duplicating
these alveolar contours into the final denture
(Fig 18).
Polished surface co n to u rs/lip su p p o rt/
retention. This patient had severe maxillary
ridge atrophy, collapsed lips, poor appear­
ance, poor retention, function, and tooth
position; implants and ridge augm entation
were co n train d icated . Polished surface
c o n to u rs, lip su p p o rt, and seal w ere
developed in a provisional denture with
conditioning m aterial th at resolved the
patient’s problems (Fig 19-21). Figures 22
and 23 show developing polished surface
contours with soft waxes. This allows for
Fig 18 ■ A lveolar contours reproduced in a wax denture
base.
 E S T H E T I C D E N T I S T R Y

Fig 19-23 ■ This patient had m axillary ridge atrophy,

so ridge a u g m entation and im p lan ts were c o n tra ­
indicated. Fig 19, to p left, finished denture com paring
alveolar ridge size and position to peripheral size and
c o n to u rs ; F ig 20 , to p c e n te r, m o u th o p e n w ide
d e m o n stra tin g p e rip h e ra l seal; F ig 21, to p rig h t,
im proved esthetics and proper lip su pport; Fig 22,
bottom left, developing contours with soft waxes in the
denture; and Fig 23, b ottom center, evaluating effects
of added wax on facial contour.

better control and permits concentrating on
specific areas; it is noted that the vermilion
surface of the patient’s right side of the upper
lip is improved and some wrinkles are
m inim ized (Fig 23). Once satisfacto ry
contours are determined in wax and tooth
position, they are reproduced in the denture
base. In this situation, the fullness was
needed over the teeth so that the necks of
the teeth were moved labially w ithout
altering the position of the incisal edges.
the patient’s wishes should be recognized
entirely or possibly negotiated to a mutually
satisfactory result.
Esthetic concerns with implant restorations.
W hen the Branem ark type of implants were
introduced, there was considerable resis­
tance by patients for esthetic reasons, for
example, the metal posts, spaces under the
prostheses, and the misalignment of the
fixtures into interproxim al areas, or pene­
trating through facial surfaces of the teeth.
Location of the fixture determ ines the
position of the prosthetic teeth which in turn
has an exceedingly im portant role in dental
esthetics. However, it is the surgeon who
places the fixtures, not the dentist. There­
fore, conducting presurgical conferences

Psychological m anagem ent/treatment

resistance. Figures 24-27 show unusual
resistance to treatm ent to the point of
sh a m e, e m b a rra ssm e n t, d isc o m fo rt,
impaired function, and extreme lack of
esthetic appearance. Expense was not a
concern, and both patients were pleasant,
cooperative, and appreciative. The first
patient maintained her right central incisor
in position by tying it with dental floss to Fig 24 ■ Central incisor tied in place with dental floss. Fig 25 ■ Facial expression after rehabilitation.
adjacent teeth (Fig 24); the same patient is
shown after prosthodontic rehabilitation in
F ig u re 25. The second p a tie n t had a
m axillary immediate provisional denture
with tissue conditioner placed 8 years earlier
(Fig 26); three m andibular anterior teeth
were held in position by calculus buildup
(Fig 27). She has resumed treatm ent and
gives no reason for the interim delay of 8
years. Again, cost was not a problem.
When the dentist is treating patients
whose concepts of beauty differ from the
norm , and continues to differ even after the Fig 26 ■ Tissue conditioner after 8 years w ithout Fig 27 ■ M andibular anterior teeth held in position with
practitioner’s rational explanations, then change. dental calculus.

Murrell: ESTHETICS AND EDENTULOUS PATIENT ■ 61-E

 E S T H E T I C D E N T I S T R Y

Fig 28 ■ P atien t with previous m axillary denture. Fig 29 ■ P atient with provisional duplicate of new denture a t wax try-in stage.

Fig 30 ■ New m axillary conventional denture, new Fig 31 ■ U pper lip support achieved with forw ard Fig 32 ■ M axillary lip support and esthetics of full face
m andibular fixed im plant denture. positioning o f the maxillary anterior teeth; esthetics of with an im plant denture patient,
lower p art o f face achieved with an im plant fixed
m andibular denture.

Fig 33 ■ P o o r lip support, to o th display, and facial contours, profile view. Fig 34 ■ P o o r lip support, tooth display, and facial contours, facial view.

Fig 35 ■ Im proved lip support, to o th display, and facial contours, profile view. Fig 36 ■ Im proved lip support, tooth display, and facial contours, facial view.

62-E ■ JADA (Special Issue) September 1988

between the surgeon and the dentist is
advocated in which the surgeon and dentist
detail the procedures including planning the
fabrication of surgical stents for fixture
placement.37 Good presurgical planning and
many improvements in techniques have
improved the esthetics of implant prostheses
and have resulted in greater acceptance by
patients.
Stents and provisionals. Figure 28 shows
a previous denture with an unsatisfactory
selection and arrangement o f anterior teeth.
Two duplicates were made of her new
denture at the wax try-in stage; one was
used for a surgical stent, the other as a
provisional denture. The patient was pleased
with her improved esthetic appearance with
the new provisional denture (Fig 29).
Implants/overcorrected lip support. Figure
30 shows the new mandibular fixed implant
denture, and the new maxillary complete
conventional denture in place. Figure 31
shows the same patient with the maxillary
anterior teeth positioned well forward of her
original natural tooth position to produce
improved upper lip support, facial contours,
and appearance. Not every patient can
tolerate this amount of change. Figure 32
shows the full facial esthetic result, the
improved effects of the upper lip support,
and no evidence of implants.
Implants/tooth position/function. Figures
33 and 34 show a patient with severe denture
instability, impaired speech, closed occlusal
vertical dim ension, lack o f upper lip
support, no anterior tooth display, a
protrusive maxillary mandibular denture
relationship, a protruded lower lip, and a
flattened mentolabial groove. Positioning
anterior teeth according to esthetic and
functional controls satisfactorily corrected
his esthetic and functional problems and
revealed a Class II jaw relationship (Fig 35,
36), which in the implant dentures resulted
in a 1714-mm cantilever of the mandibular
central incisors, anterior to the center
implant fixture.
Conclusion
As important as complete dentures are to
esthetic appearance and masticatory and
phonetic function, the successful rehabili­
tation of the edentulous patient can no
longer be limited to the proper selection and
arrangement of teeth. When teeth are lost,
people lose more than function; they suffer
a psychological shock that leaves them with
a loss of self-esteem, and other anxieties.
New techniques to improve denture
fabrication continue to be developed, and
dentists are being advised to listen to their
patients, to address their desires, to show
concern and caring, and to psychologically
manage their edentulous patients. Other
relevant factors to psychological manage­
ment include: the compatibility of the
dentist-patient attitudes, personalities of the
patient, dentist, and staff, and the knowl­
edge, organization, timeliness, and under­
standing of the patient’s problems by the
dentist and staff. Finally, the comfort,
cleanliness, and decor of the office, oper-
atories, and equipment all contribute to the
treatment and environment for the total
esthetic restoration o f the edentulous
patient.
Dr. M urrell is a clinical professor of restorative
dentistry, University o f Southern C alifornia School of
D entistry, and is a private practitioner limiting his
practice to fixed and removable prosthodontics. 1101
Sepulveda Blvd, suite 200, M anhattan Beach, C A 90266.
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