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The role of the mandibular anterior teeth in complete denture esthetics
REMOVABLE SECTION
PROSTHODONTICS
EDITORS
LOUIS BLATTERFEIN
S. HOWARD
PAYNE
GEORGE
The role of the mandibular denture esthetics R. E. Cade, D.M.D., M.S.* Medical College of Virginia, School of Dentistry,
anterior
Richmond,
T
A. ZARB
teeth in complete
Va.
Other findings of the research were: (1) people’ with short upper lips displayed more maxillary tooth structure than people with long upper lips; (2) the longer the upper lip, the more the mandibular teeth were exposed; (3) men displayed more of the mandibular incisors (1.23 mm) than women (0.49 mm). The authors concluded that the mandibular arch did play an esthetically significant role’in constructing dentures. They further suggested that it had not been sufficiently emphasized in previous literature. Heartwell and Rahn” have contended that the interincisal distance increases with age and that therefore the mandibular teeth become more visible. Increased visibility can result from loss of muscle tonus which can allow the lower lip to sag and the upper lip to drop. In Heartwell and Rahn’s judgment, to attempt to make the teeth of the older patient visible to the same extent they were visible when the patient was young may result in an incorrect orientation of the occlusal plane.
In the study of dentistry, too little interest has been focused directly on complete denture esthetics. The literature discusses techniques for the use of phonetics, position of maxillary anterior teeth, and preextraction records to construct esthetically attractive dentures. To a large degree, DeVan’s’ position regarding prosthodontics has been representative of that which has prevailed. He has suggested that the objective of dentistry should be based upon the preservation of what remains as opposed to the meticulous restoration of what is missing. A growing trend is being evidenced throughout the nation in which health professionals are held legally accountable for the treatment they provide. In view of this trend, it is incumbent upon health professionals to provide their patients with the best possible service and treatment from a mechanically comfortable standpoint as well as from the standpoint of the patient’s psychological satisfaction. Of those practitioners who have challenged the adequacy of traditional methods in developing esthetically attractive dentures, Vig and Brundo” have been among the first group of individuals to conduct research. Their study focused on the exposure of natural maxillary and mandibular teeth. This research entailed surveying persons of varied ages to determine (1) the relationship of lips and teeth and (2) changes that occurred with aging in anterior tooth exposure. The results of the study suggested that accepted guidelines for setting anterior teeth might be misleading, because the mandibular arch was found to play a greater role than had previously been reflected in the literature. Specifically, the data indicated that among patients over 60 years old, the mandibular incisor teeth were displayed to approximately the same extent that maxillary incisor teeth were displayed by patients under 30 years of age.
RESEARCH
Presented at the Carl 0. Boucher Prosthodontic Conference, Columbus, Ohio. *Assistant Professor, Department of Removable Prosthodontics.
The research sample consisted of individuals who (I) had lost no more than two posterior teeth (excluding third molars) and (2) were between 20 and 65 years of age. Potential participants were
368
OCTOBER
1979
VOLUME
42
NUMBER
4
ROLE OF THE MANDIBULAR FACIAL EXPRESSION
ARCH
IN
In an effort to expand upon the information presently available, research was undertaken to explore the role played by the mandibular arch in a variety of facial expressions. Specifically, the study focused upon the role played by the mandibular anterior teeth in speaking, in smiling, and in resting facial expressions. Of particular interest was the degree to which (1) the mandibular anterior teeth were revealed exclusively in these facial expressions, (2) the maxillary teeth were revealed exclusively, or (3) the anterior teeth of the two dental arches were equally revealed. METHODOLOGY
0022-3913/79/100368
+ 03$00.30/00
1979 The C. V. Mosby
Co.
MANDIBIJLAR
ANTERIOR
l Mandtbular 0 Mar~llory
TEETH
AND
ESTHETICS
Arch Arch
7
00
69
60 8 40
E I
20
C
20- 29 YEARS
30-39
YEARS
60 s
I2.1 I
40 YEARS
40
.29
OR
30-
YEARS
‘EARS
40
OLDER
AGE
Fig. 1. Comparative analysis of the appearance of the mandibularand maxillary anterior teeth in resting,speaking, and smiling positions among both men and
YEARS OLDER
OR
Fig. 2. Comparative analysis of the appearance of the mandibular and maxillary anterior teeth in resting, speaking, and smiling facial positions among men.
women.
Table I. Percent of individuals displaying maxillary and mandibular anterior teeth
8Mondibulor q Mmllory
Arch Arch
Position Arch
Resting
Maxillary
50%
Mandibular
50%
Speaking
Smiling
37% 63%
87% 13%
identified by the Dental Clinic of the Ohio State University. Those who agreed to participate were scheduled for the observation phase of the study. Fifty-eight women and 66 men participated in the study. Their ageswere grouped into categories of 20 to 29 years, 30 to 39 years, and 40 years or older. Sixty-five participants were in the first group, 19 were in the second, and 40 were in the oldest group. Each subject was observed on an individual basis by two graduate dental students. The subject was seated in a dental chair which was individually adjusted so that the maxillary arch was parallel to the floor. The research assistants were seated in adjustable dental stools, approximately 6 feet from the patient’s nose. As the subjects responded to the questions and read a poem, the research assistants paid special attention to the amount of their maxillary and mandibular anterior teeth showing in the various facial expressions.Attention was focused on whether
THE JOURNAL
OF PROSTHETIC
DENTISTRY
100
00
60 s 40
20
0 20 - 29
YEARS
30-39
YEARS 4o
EeRRs
(
r
Fig. 3. Comparative analysisof the appearanceof the mandibularand maxillary anterior teeth in resting,speaking, and smiling facial positionsamongwomen. only upper or lower teeth were revealed exclusively by the subjects in the various facial expressions.Also noted were instances where the subjects showed maxillary and mandibular teeth equally in speaking, smiling, or resting situations. The assistantsrecorded their observations on data sheets.Frequencies in which maxillary or mandibular teeth dominated or were equally shared in the
369
CADE
Table II. Groups
displaying
mandibular
anterior Lower
Group
teeth at 0.01 level
arch displayed to greater extent than upper arch Group
compared
Men/Women (all ages) Men 40 years or older Women 40 years or older Men 20-29 years or older Women 20-29 years or older Subjects 40 years or older Subjects 20-29 years or older Men 20-29 yeprs or older Men 40 years or older
Men Men
40 years
Men
20-29
Subjects Subjects Men 40 Men 40
%
or older
years
40 years 40 years years or years or
facial expressions were tabulated. Those occasions where the assistants made the identical observations were noted on the summary data sheets.
RESULTS The data collected through the research are summarized in the following figures and tables. Table I and Fig. 1 present a Comparative analysis among subjects showing mandibular and maxillary anterior teeth in a variety of facial expressions. In Fig. 2 a comparison is made between the visibility of the maxillary and mandibular teeth among men in various age groups. In Fig. 3 the same comparison is made among women. Table II presents data reflecting only situations where the display of the mandibular anterior teeth in facial expressions was significant at the 0.01 level. The chi-square value shown measures the association between use of the mandibular arch among various groups. This study clearly showed that the mandibular anterior teeth do play an important role in patient appearance. These teeth were displayed in resting, smiling, and speaking facial expressions. The mandibular anterior teeth were displayed to a greater extent that the maxillary anterior teeth in at least half or more of the resting and speaking facial expressions. Also, a positive relationship appeared to exist between visibility of the mandibular anterior teeth (in the various facial expressions) and age and sex. An increase in the visibility of the mandibular anterior teeth was found in persons 40 years of age or older. Men displayed mandibular anterior teeth in facial expressions to a greater extent than women.
IMPLICATIONS
OF THE RESEARCH
Research focusing teeth is inadequately
370
of significance
upon the mandibular anterior dealt with in the literature. The
or older or older older older
Facial
position
X’
74 69
Resting Resting
14.9 10.4
74
Resting
4.2
59 56 58 60
Resting Speaking Resting Speaking
10.1 6.2 11.3 5.5
findings of this study as well as that of Vig and Brundo’ can be used by dentists to construct dentures which are esthetically attractive and natural in appearance. Not only do the data suggest a significant role of the mandibular anterior teeth, but the types of individuals who are likely to display these teeth to a greater extent in a variety of facial expressions are also noted. The study clearly suggests that if the dentist is fabricating dentures for an individual 40 or more years of age, the mandibular anterior teeth should be given as much consideration as the maxillary anterior teeth in esthetic evaluation. The data suggest that the same consideration is important when constructing dentures for men. While it is not the intent to propose that this rule applies for all men and all persons 40 years of age or older, the findings of this study justify esthetic consideration of the mandibular anterior teeth when making dentures for the two groups that have been discussed. This research points to a need for further study on this subject, as it clearly confirms that a significant role is played by the mandibular anterior teeth in certain facial expressions.
REFERENCES 1. 2. 3.
DeVan, M.: Biological demands of complete dentures. J Am Dent Assoc 45:526, 1952. Vig, R., and Brundo, G.: The kinetics of anterior tooth display. J PROSTHET DENT 39:502, 1978. Heartwell, C., and Rahn, A.: Syllabus of Complete Dentures, ed 3. Philadelphia, 1969, W. B. Saunders Co., p 279.
Reprint requests to: DR. R. E. CADE MEDICAL
COLLEGE
OF VIRGINIA
SCHOOL OF DENTISTRY RICHMOND, VA. 23298
OCTOBER
1979
VOLUME
42
NUMBER
4
PROSTHODONTICS
EDITORS
LOUIS BLATTERFEIN
S. HOWARD
PAYNE
GEORGE
The role of the mandibular denture esthetics R. E. Cade, D.M.D., M.S.* Medical College of Virginia, School of Dentistry,
anterior
Richmond,
T
A. ZARB
teeth in complete
Va.
Other findings of the research were: (1) people’ with short upper lips displayed more maxillary tooth structure than people with long upper lips; (2) the longer the upper lip, the more the mandibular teeth were exposed; (3) men displayed more of the mandibular incisors (1.23 mm) than women (0.49 mm). The authors concluded that the mandibular arch did play an esthetically significant role’in constructing dentures. They further suggested that it had not been sufficiently emphasized in previous literature. Heartwell and Rahn” have contended that the interincisal distance increases with age and that therefore the mandibular teeth become more visible. Increased visibility can result from loss of muscle tonus which can allow the lower lip to sag and the upper lip to drop. In Heartwell and Rahn’s judgment, to attempt to make the teeth of the older patient visible to the same extent they were visible when the patient was young may result in an incorrect orientation of the occlusal plane.
In the study of dentistry, too little interest has been focused directly on complete denture esthetics. The literature discusses techniques for the use of phonetics, position of maxillary anterior teeth, and preextraction records to construct esthetically attractive dentures. To a large degree, DeVan’s’ position regarding prosthodontics has been representative of that which has prevailed. He has suggested that the objective of dentistry should be based upon the preservation of what remains as opposed to the meticulous restoration of what is missing. A growing trend is being evidenced throughout the nation in which health professionals are held legally accountable for the treatment they provide. In view of this trend, it is incumbent upon health professionals to provide their patients with the best possible service and treatment from a mechanically comfortable standpoint as well as from the standpoint of the patient’s psychological satisfaction. Of those practitioners who have challenged the adequacy of traditional methods in developing esthetically attractive dentures, Vig and Brundo” have been among the first group of individuals to conduct research. Their study focused on the exposure of natural maxillary and mandibular teeth. This research entailed surveying persons of varied ages to determine (1) the relationship of lips and teeth and (2) changes that occurred with aging in anterior tooth exposure. The results of the study suggested that accepted guidelines for setting anterior teeth might be misleading, because the mandibular arch was found to play a greater role than had previously been reflected in the literature. Specifically, the data indicated that among patients over 60 years old, the mandibular incisor teeth were displayed to approximately the same extent that maxillary incisor teeth were displayed by patients under 30 years of age.
RESEARCH
Presented at the Carl 0. Boucher Prosthodontic Conference, Columbus, Ohio. *Assistant Professor, Department of Removable Prosthodontics.
The research sample consisted of individuals who (I) had lost no more than two posterior teeth (excluding third molars) and (2) were between 20 and 65 years of age. Potential participants were
368
OCTOBER
1979
VOLUME
42
NUMBER
4
ROLE OF THE MANDIBULAR FACIAL EXPRESSION
ARCH
IN
In an effort to expand upon the information presently available, research was undertaken to explore the role played by the mandibular arch in a variety of facial expressions. Specifically, the study focused upon the role played by the mandibular anterior teeth in speaking, in smiling, and in resting facial expressions. Of particular interest was the degree to which (1) the mandibular anterior teeth were revealed exclusively in these facial expressions, (2) the maxillary teeth were revealed exclusively, or (3) the anterior teeth of the two dental arches were equally revealed. METHODOLOGY
0022-3913/79/100368
+ 03$00.30/00
1979 The C. V. Mosby
Co.
MANDIBIJLAR
ANTERIOR
l Mandtbular 0 Mar~llory
TEETH
AND
ESTHETICS
Arch Arch
7
00
69
60 8 40
E I
20
C
20- 29 YEARS
30-39
YEARS
60 s
I2.1 I
40 YEARS
40
.29
OR
30-
YEARS
‘EARS
40
OLDER
AGE
Fig. 1. Comparative analysis of the appearance of the mandibularand maxillary anterior teeth in resting,speaking, and smiling positions among both men and
YEARS OLDER
OR
Fig. 2. Comparative analysis of the appearance of the mandibular and maxillary anterior teeth in resting, speaking, and smiling facial positions among men.
women.
Table I. Percent of individuals displaying maxillary and mandibular anterior teeth
8Mondibulor q Mmllory
Arch Arch
Position Arch
Resting
Maxillary
50%
Mandibular
50%
Speaking
Smiling
37% 63%
87% 13%
identified by the Dental Clinic of the Ohio State University. Those who agreed to participate were scheduled for the observation phase of the study. Fifty-eight women and 66 men participated in the study. Their ageswere grouped into categories of 20 to 29 years, 30 to 39 years, and 40 years or older. Sixty-five participants were in the first group, 19 were in the second, and 40 were in the oldest group. Each subject was observed on an individual basis by two graduate dental students. The subject was seated in a dental chair which was individually adjusted so that the maxillary arch was parallel to the floor. The research assistants were seated in adjustable dental stools, approximately 6 feet from the patient’s nose. As the subjects responded to the questions and read a poem, the research assistants paid special attention to the amount of their maxillary and mandibular anterior teeth showing in the various facial expressions.Attention was focused on whether
THE JOURNAL
OF PROSTHETIC
DENTISTRY
100
00
60 s 40
20
0 20 - 29
YEARS
30-39
YEARS 4o
EeRRs
(
r
Fig. 3. Comparative analysisof the appearanceof the mandibularand maxillary anterior teeth in resting,speaking, and smiling facial positionsamongwomen. only upper or lower teeth were revealed exclusively by the subjects in the various facial expressions.Also noted were instances where the subjects showed maxillary and mandibular teeth equally in speaking, smiling, or resting situations. The assistantsrecorded their observations on data sheets.Frequencies in which maxillary or mandibular teeth dominated or were equally shared in the
369
CADE
Table II. Groups
displaying
mandibular
anterior Lower
Group
teeth at 0.01 level
arch displayed to greater extent than upper arch Group
compared
Men/Women (all ages) Men 40 years or older Women 40 years or older Men 20-29 years or older Women 20-29 years or older Subjects 40 years or older Subjects 20-29 years or older Men 20-29 yeprs or older Men 40 years or older
Men Men
40 years
Men
20-29
Subjects Subjects Men 40 Men 40
%
or older
years
40 years 40 years years or years or
facial expressions were tabulated. Those occasions where the assistants made the identical observations were noted on the summary data sheets.
RESULTS The data collected through the research are summarized in the following figures and tables. Table I and Fig. 1 present a Comparative analysis among subjects showing mandibular and maxillary anterior teeth in a variety of facial expressions. In Fig. 2 a comparison is made between the visibility of the maxillary and mandibular teeth among men in various age groups. In Fig. 3 the same comparison is made among women. Table II presents data reflecting only situations where the display of the mandibular anterior teeth in facial expressions was significant at the 0.01 level. The chi-square value shown measures the association between use of the mandibular arch among various groups. This study clearly showed that the mandibular anterior teeth do play an important role in patient appearance. These teeth were displayed in resting, smiling, and speaking facial expressions. The mandibular anterior teeth were displayed to a greater extent that the maxillary anterior teeth in at least half or more of the resting and speaking facial expressions. Also, a positive relationship appeared to exist between visibility of the mandibular anterior teeth (in the various facial expressions) and age and sex. An increase in the visibility of the mandibular anterior teeth was found in persons 40 years of age or older. Men displayed mandibular anterior teeth in facial expressions to a greater extent than women.
IMPLICATIONS
OF THE RESEARCH
Research focusing teeth is inadequately
370
of significance
upon the mandibular anterior dealt with in the literature. The
or older or older older older
Facial
position
X’
74 69
Resting Resting
14.9 10.4
74
Resting
4.2
59 56 58 60
Resting Speaking Resting Speaking
10.1 6.2 11.3 5.5
findings of this study as well as that of Vig and Brundo’ can be used by dentists to construct dentures which are esthetically attractive and natural in appearance. Not only do the data suggest a significant role of the mandibular anterior teeth, but the types of individuals who are likely to display these teeth to a greater extent in a variety of facial expressions are also noted. The study clearly suggests that if the dentist is fabricating dentures for an individual 40 or more years of age, the mandibular anterior teeth should be given as much consideration as the maxillary anterior teeth in esthetic evaluation. The data suggest that the same consideration is important when constructing dentures for men. While it is not the intent to propose that this rule applies for all men and all persons 40 years of age or older, the findings of this study justify esthetic consideration of the mandibular anterior teeth when making dentures for the two groups that have been discussed. This research points to a need for further study on this subject, as it clearly confirms that a significant role is played by the mandibular anterior teeth in certain facial expressions.
REFERENCES 1. 2. 3.
DeVan, M.: Biological demands of complete dentures. J Am Dent Assoc 45:526, 1952. Vig, R., and Brundo, G.: The kinetics of anterior tooth display. J PROSTHET DENT 39:502, 1978. Heartwell, C., and Rahn, A.: Syllabus of Complete Dentures, ed 3. Philadelphia, 1969, W. B. Saunders Co., p 279.
Reprint requests to: DR. R. E. CADE MEDICAL
COLLEGE
OF VIRGINIA
SCHOOL OF DENTISTRY RICHMOND, VA. 23298
OCTOBER
1979
VOLUME
42
NUMBER
4