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Esthetics in Denture Construction*
ESTHETICS IN DENTURE CONSTRUCTION* By IRVING R. HARDY, D.M.D., New York City
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E F O R E enum erating or attem pting to describe the aids to esthetic con siderations w hich m ay be employed in th e construction of dentures, and w hich I hope to bring again to your a t tention, I shall endeavor to point out w h at I believe is a crying need fo r greater atten tio n to th e appearance of the appli ances th a t w e dentists construct. T h e w earers of dentures, according to my observations, fall into tw o groups as fa r as th e appearance of the teeth is concerned. T h e m ajo rity are w earing d entures w hich are n o t only obviously artificial, but, in m any cases, also posi tively grotesque looking. W e are forced to believe th a t the m en w ho construct such dentures take the easy w ay out, per haps leaving the m atters so vitally im p o rta n t to proper appearance entirely in the hands of a laboratory, and then persuading the patient to accept the den tures, unsatisfactory though he may know them to be. P atien ts w ho are w earing dentures of this type are not receiving tru ly professional service, and their teeth, even though they function creditably, can never be any g reat source of satisfaction to them , no r cast any credit on the prac titio n er w ho m ade them. O f course, some patients m ay in tim e become som ew hat accustom ed to an u n a ttractiv e appearance, accepting it as part *Read before the Section on Full Denture Prosthesis at the Seventy-Fourth Annual Session of the American Dental Associa tion, Buffalo, N. Y., Sept. 13, 1933. Jour. A .D . A ., A p r il 1933
of an inevitable b urden of those who w ear dentures, b u t there are m any sensi tive souls w ho have suffered considerable m ental agony, due solely to a realization of th e fact th a t th eir artificial teeth w ere indeed obviously artificial. A second, and I am sorry to state, much sm aller group of d en tu re w earers have been strong-m inded enough n o t to accept the m ediocre p roduct w hich has been foisted on th e m ore docile o r have been discrim inating or fo rtu n a te enough to select a p ractitio n er w ho w as not averse to p u ttin g at least some of his own handiw ork into the construction of his d e n tu re s; a m an w ho w as not content to pass a standardized, stereotyped prod uct along to his patient. T h is m an may have employed one or all of the aids and artifices w hich can be used to prom ote esthetic considerations, an d w ill have produced a result w hich m ay n ot be perfect in all cases, b u t w hich, in many, w ill be so n a tu ra l looking as to v irtu ally defy detection. I realize th a t, in m any cases, it is extrem ely difficult to achieve exactly the esthetic result th a t m ight be described as perfect, b u t I have found th a t the proper em ploym ent of the follow ing processes w ill do a g reat deal tow ard enabling the dentist to build in to his cases a degree of naturalness n o t to be achieved w ith o u t such aids. I t is my belief th at, in the vast m ajo r ity of cases, the tooth form, to o th a r rangem ent and tooth color w ith w hich
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H a rd y — E sthetics in D en tu re C onstruction N a tu re equips an individual blend w ell, and are generally harm onious w ith the oth er facial characteristics. T h erefo re, w hen w e are fo rtu n ate enough to have seen the n atu ra l teeth, w e had best take steps to register the appearance before the te eth are lost, and to this end w e employ photography. T h e m ost im portant picture to be taken is the one in profile, to register the facial contours and especially the lip positions, for it is proposed, in th e fin ished dentures, to build the lips out to the position th a t they originally occupied, and it m ight be difficult to achieve this result w ith o u t an accurate record as a guide. In m any cases, there has been a distinct closure of the bite, w hich is due to the loss of some of the posterior teeth, and it is found wise to open the bite w ith blocks of w ax or cotton rolls gripped betw een the rem aining posterior teeth before posing the patient fo r a profile picture, so th at, afte r the teeth have been removed, the photograph m ay be used for reference in building bite rim s to proper contour. P ictu re s taken of the fu ll face, both in a position of rest and w ith th e lips draw n back to show the teeth, may also be taken and w ill always serve as refer ence guides d uring the process of con stru ctin g dentures. A n article by B. L . H ooper gave me most of my ideas regarding the applica tion of photography to prosthetic w ork, and C . J . Stansbery1 has presented a profile enlargem ent m ethod w hich I have g ratefully adopted. A second invaluable aid in establishing esthetic values is the securing of proper preextraction models of the n a tu ra l teeth. O ne of these is taken w ith the bite1. Stansbery, C. J.: Functional Position Checkbite Technic, J.A.D.A., 16:421 (M arch) 1929.
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opening blocks used for the photographs in place, a piece of m odeling com pound, usually backed up by a strip of aircham ber m etal, being m olded over the labial surfaces of both the upper and low er teeth w hile th e teeth are in centric occlusion. A fte r this is chilled, removed from the m outh and poured in plaster, w e have in one m odel a replica of the visible surfaces of the an terio r teeth, the overbite, o verjet an d relative positions of the m an d ib u lar to th e m axillary teeth. I t w ill prove a distinct aid in assuring proper tooth arran g em en t in o u r dentures. A high-sided tra y filled w ith w arm beeswax is used to take an impression of the n a tu ra l te eth w h ile they are still in the m outh, and, afte r the teeth are ex tracted, they are set in position in this beeswax impression, and plaster poured about th eir roots to retain them . T h ese teeth are to be soaked in w a te r fo r a few days before w e construct the dentures, to restore th eir color, w hich w ill change if they are kept d ry ; an d th eir use as a guide w ill enable us to im itate alm ost exactly individual tooth form an d tooth color. W ith the afore-m entioned records, w e have secured invaluable aid to an esthetic result, and operators w ho fail to secure them , or th eir equivalent, not only place themselves u n d er a severe handicap by sacrificing the o p portunity to do so, b ut are guilty of som ething m ore th an casual oversight in neglecting an opportunity for serving th eir patients. In constructing dentures for cases in w hich w e have these records, teeth are selected from a stock mold, as n ear in form an d Golor to the n atu ra l teeth as possible. I t w ill, of course, be impossible to get exact m atches of both form and color, b u t the tooth form can be readily changed by grinding and the color can be altered by shading w ith m ineral stains.
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M y equipm ent fo r this w o rk consists of a furnace w hich, w ith a rheostat to control the heat, represents an investm ent of less th an $25. A few bottles of “ 1600” stain, some “ 1600 glaze,” a glass m ixing slab, some brushes and distilled w ate r constitute the rest of the equipm ent.
is to replace once occupied. T h is care in tooth form and to o th arran g em en t is expended only on the six or eight an terio r teeth, the teeth posterior to th e first bicuspids, of course, being placed in posi tions best suited to th e prom otion of stability in the denture. I t is wise now to check the resu lt in the m outh, to m ake sure th a t th e tooth form an d arrangem ent are satisfactory, and to m ake such modifications as may be necessary. W h e n these changes, if any are required, have been m ade, the next step is the use of the previously m entioned m ineral stains fo r coloring the teeth. T h e an terio r teeth are rem oved from the baseplate by w arm in g th e w ax a little, each to o th being carefu lly re moved. T h u s, a socket w ill be le ft in the w ax into w hich each to o th m ay be reset accurately w hen the next step is com pleted.
M a y w e suppose, now, th a t our prob lem is th e construction of a m axillary den ture to occlude w ith n a tu ra l low er teeth. T h e impression has been taken and the bites have been registered, the casts m ouiited on the a rticu la to r and the proper stock teeth selected, the next step being th e setting up of the teeth. W ith the casts supporting the p atien t’s extracted n a tu ra l teeth and the plaster model of the upper and low er teeth in centric occlusion as guides, I grind each porcelain to o th to proper size and shape, im itating in the porcelain enam el ir regularities, abraded and eroded areas and any deviations from perfect tooth sym m etry th a t it is deemed wise to repro duce. A s these teeth are ground, they are set up on the w ax baseplate of the m axillary cast, and by constant reference to the centric occlusion model, each a r ti ficial to o th is placed in exactly the same position th a t the n a tu ra l tooth w hich it
I t is essential th a t th e teeth be care fully cleaned before any staining is done, and to this end they are scrubbed w ith a stiff bristle brush and soap an d w ate r, a fte r w hich they are boiled in a strong solution of w ashing pow der an d w ater. T h is boiling removes any w ax o r grease w hich m ight resist the action of soap and w a te r only. I find it wise to exam ine the teeth w ith a glass before going fa rth e r w ith th e w ork, to m ake sure th a t the surface to be colored is really clean and free from specks, w hich m ig h t escape the eye w ith o u t th e use of m agnification. T h e actual application of th e stains used is very difficult to describe, b ut it is n o t of itself very difficult. W ith th e n a tu ra l extracted teeth as a guide for the colors to be used. I m ix a little of each color o r com bination of colors of stain on a glass slab, using distilled w a te r as a vehicle, and, holding th e to o th in a pair of cotton pliers, paint th e colors on
I should like to go into detail reg ard ing th e coloring of stock teeth w ith m ineral stains, fo r I believe it to be one of the m ajo r aids fo r producing n atu ra llooking artificial teeth. T h e idea is by no m eans new . L aw rence B aker, of Boston, w ro te on the subject tw enty-five years ago, and did beautiful w o rk w ith stains a t th a t tim e. T od ay , since w e have at hand such excellent and, at the same time, very inexpensive equipm ent for the purpose, it seems strange th a t this w o rk is not m ore generally done, as it enables the operator to produce results in denture construction th a t are scarcely obtainable in any other w ay.
H a rd y— E sthetics in D e n tu re Construction the tooth surface. T h e furnace having been previously brought to the proper heat, I hold the tooth up before the open door fo r a few seconds to fix th e colors a fte r they have been applied, and then set th e tooth on a silex covered fire clay tra y w hich is of sufficient size to ac com m odate six teeth. T h e tray, w ith the teeth so laid upon it th a t they do not touch each other, is introduced ju st inside the door of the furnace, left there for tw o or three m inutes, and then p u t inside the furnace and the asbestos block door p u t into place. F rom three to five m in utes is tim e enough to fire the colors, a fte r w hich the .tray can be removed from th e furnace, carefully protected w ith a cover to prevent d rafts from checking the porcelain and allow ed to cool. A fte r the teeth are cooled, the glaze is painted on in a generous coating. T h is glaze is tran sp aren t and is not to be con fused w ith some of the higher fusing glazes w hich, if applied in a heavy coat ing, tend to w ard opacity, and produce w h ite areas. In applying the glaze, w hich is a pow der and is m ixed w ith distilled w a te r as a vehicle, it is not absolutely necessary to have an even coat applied all over the surface to be glazed, for, d u rin g the firing, it seems th a t the coat ing evens itself o u t nicely. T h e teeth are now fired a second tim e in exactly the same w ay th a t they w ere w hen the stains w ere fused, and, after they are cool, w e find th a t the stock teeth have taken on a very life-like ap pearance, although they are sometimes a trifle too shiny. T h is high glaze m ay be reduced to a ra th e r d ull gloss by holding the glazed surface, liberally covered w ith w et pumice and kept continually so covered, against a rubber w heel m ounted on the lathe. W h e n this too shiny sur face has been reduced to a ra th e r satin finish, it w ill be seen th a t application of
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the heavy coat of th e glaze over the underlying stains gives an effect of depth of color, w hich is extrem ely life-like. F o r some years, I had been using high fusing stains, w ith an overlayer of 1,700 degree glaze, b u t the m ethod here briefly described w as suggested to me by H u b e rt K ohrm an, of D anbury, Conn., and it gives b etter results th an I ever achieved w ith the higher fusing glazes employed in a sim ilar m anner. I tru s t th a t this technic for coloring stock teeth w ill not seem so tim e-con sum ing as to preclude its use. T h e m ethod I have often seen attem pted of using m ineral stains on u n altered stock teeth over the original glaze is such an obvious subterfuge th a t it may ten d to accentuate, ra th e r th an conceal, the a rti ficiality of a prosthetic appliance, an d I w ould ask th a t those of you w ho have seen stains so employed, and w ho have therefore judged th eir use as of dubious value, give them an o th er try , using the m ethod here outlined, and I believe you w ill find in them a w eapon fo r com bating obvious artificiality w hich w ill serve you and your p atients m ost creditably. T h is paper has so fa r dealt only w ith the handling of those cases in w hich efforts are m ade to supply a patient w ith teeth w hich are in appearance very simi la r to his n a tu ra l o n es; th e com paratively simple m a tte r of faith fu lly im itating the m ost visible p arts of the n atu ra l d en ti tion. T h e task of rebuilding a m outh w hen I have never seen the n atu ra l teeth is to me m uch m ore of a problem. In such cases, I find th a t considerable help may often be derived from a ju d i cious use of the fact of fam ily resemblance. A w om an, perhaps 60 years of age, w ea r ing unsuitable dentures applies for new ones. I f inquiry should reveal the fact th a t this w om an has a d au ghter whose facial characteristics are like her
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m o ther’s, I feel justified in copying the tooth form and tooth arrangem ent of the d au g h ter’s n atu ra l teeth w hen m aking artificial ones for the m other. T o avoid the distinctly incongruous effect of young teeth in an older individual, the precau tion is of course taken of selecting a basic shade w hich w ill be consistent w ith the years and com plexion of the patient, and the teeth are properly aged by g rin d ing th e incisal edges to sim ulate w ear and the necks to im itate erosion, and by artistically shading the teeth w ith m in eral stains. I find th a t the factor of fam ily resemblance may prove a very distinct aid in puzzling cases w hen the m ore direct guidance of a few rem aining n a tu ra l teeth is lacking. In th a t great num ber of cases in w hich th ere are no n atu ra l teeth rem aining nor is assistance from a m em ber of the fam ily in obtaining proper tooth form and a r rangem ent available, J . L eon W illia m s’ m ethod of selection w ill of course prove o u r only salvation. I believe th a t in ap plying this happily discovered form ula, care should be taken to select teeth of adequate size, for, in observing the ap pearance of m any dentures, I have come to the conclusion th a t one of the most common violations of the esthetic precept is the use of teeth too sm all for the case, and it is often an e rro r w hich at first glance brands the restoration as spurious. W hen the proper teeth have been selected, the task of arran g in g them in a n a tu ra l looking set-up can be arrived at, as far as I know, only by a tria l and erro r method, follow ing the arch form as a guide, and avoiding w here possible too g reat a sym m etry in the arrangem ent. Sometimes a patient likes to rem em ber th a t her n atu ra l teeth w ere very regular, and w ill insist on a ra th e r sym m etrical arrangem ent of the artificial teeth. If I m ust bow to the p atien t’s wishes in the
m atter (an d I certainly try to have the patient believe th a t I am open to sug gestions from h im ), I find th a t by properly g rin d in g and coloring the in dividual teeth, th a t is to say by m aking the individual teeth m ore o r less asym m etrical, I can arran g e them in an even set-up and still entirely avoid th at deadly look of a row of porcelain blocks w hich brands so m any dentures as a rti ficial. T h e introduction of a gold filling or inlay may be a g reat help in breaking the m onotony of a sym m etrical set-up. F illings of a com pound type are p refer able: on th e an terio r teeth, mesio-incisal or disto-incisal fillings; on the bicuspids, mesioclusal types. T e e th w hich are to receive these fillings are colored slightly bluish aro u n d the m arg in of th e filling, in im itation of th e shadow cast by the gold th ro u g h the enamel, o r even the tiny leakage often seen in fillings w hich have been some years in place. Some of the rubber substitutes w ith w hich the profession is now experim ent ing and w hich seem to be im proving as they are used and perfected w ill, w e hope, prove of great aid in those high lip line cases in w hich, up to th e present time, it has been extrem ely difficult to achieve anything like a proper esthetic result. I have heard prosthetists sug gest th a t th e use of long teeth in such cases to avoid show ing any rubber w as a w ay out of th e difficulty, b u t this cure in practice often proves w orse th a n the show ing of vulcanite. I have also seen the problem m et by placing th e denture so fa r up u n d er the lip th a t w hile the patient tru ly showed no rubber, neither did he show any teeth. A ll together, there has been b ut one answ er to these cases, and th a t is the rath e r expensive expedient of a continuous gum denture, and even this solution is n o t an ideal one,
H a rd y— E sthetics in D en tu re C onstruction for the w eight and fragility of the den tu re m ight be nearly as g reat a draw back as its expense. 1 have had considerable success in these cases by em ploying one of the phenol-resin com pounds as a veneer over an underlying rubber base, in this w ay securing a strong foundation, w ith a n a tu ra l looking gum , w hich, if it dete riorates, may be quite readily replaced w ith o u t disturbing th e body of the den tu re. T h e veneer m ust be fairly heavy to look w ell, as otherw ise the underlying rubber tends to show thro u g h th e facing and destroy the artistic effect. T h is m ethod is, of course, a fra n k compromise, but it is nevertheless a distinct aid in achieving a lifelike im itation of n atu ra l gum w here vulcanite rubber w ould not only m ar but, w e m ight say, nullify all the good effects achieved by a proper a r rangem ent and coloring of the teeth themselves. P erhaps the various steps in technic herein enum erated as aids to esthetic re sults in denture w ork m ay seem to some superfluous, but I have learned from sad experience th a t the task is difficult w hen every means possible is employed to bring about a proper result, and th a t I cannot therefore afford to ignore or neglect any aid, artifice, means or m ethod w hich w ill lift the product of my handi w ork out of the limbo of false teeth, and make it a factor of prim e im portance in restoring to the patient his n atu ra l appearance. 2 East Fifty-Fourth Street. DISCUSSION M i l t o n Cohen, N e w Y o rk C ity.: Dr. Hardy stresses the case of the patient who has some of his anterior natural teeth, a type of case which is not nearly so common as the wholly edentulous one. T he skill of the dentist is more heavily taxed with the latter type, and it is this patient who must be pleased far
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more often than the one who has some of his own teeth left. Usually, staining of artificial porcelain teeth is done against the patient’s wishes, and is is finally accepted only after a trial in the mouth of the patient, and then only if it is not overdone. It is difficult to overcome the natural antipathy of the pa tient to a truthful reproduction of his own teeth where fillings and decay are apparent when it is his desire to improve his appear ance with a newer, cleaner and better look ing arrangem ent of teeth in a denture, but, for all that, a light and not too obvious staining of the teeth is very desirable and the use of stains should be encouraged by the dentist. I take exception to only one statement which Dr. H ardy has made, that concerning the continuous gum case. He practically admits that this type of restora tion most closely approaches the ideal, and then dismisses its use in an off-hand manner because of the expense involved. If it is agreed that, in addition to the restoration of the natural functions, the construction of a continuous gum case offers greater esthetic possibilities than any other prosthetic product now at the command of the dentist, the ques tion of expense should be given the least amount of consideration, it any at all. T he advantages of the continuous gum case over the vulcanite and the other resinous substitutes by far outweigh the objections of expense. T he very desirable reaction of the tissues to the platinum base and the smooth porcelain surface; the therm al changes which are easily registered on all the underlying soft tissues; the true sense of taste that is communicated to the palate; the absolute cleanliness of the denture from a hygienic standpoint and freedom from attacks from the products of bacterial reaction on the platinum and the porcelain, and the ease with which it can be kept in a state of cleanliness are advantages accruing from the use of the continuous gum case. Dr. H ardy’s objection to its weight is over come by the use of a lighter gage platinum base; for example, No. 32 or No. 36, which has been employed with great success, and, as to the fragility of the material, instruc tions to the patient to use due caution while cleaning the denture will obviate any dif ficulty from that source. A fracture of the material while in function in the mouth is of rare occurrence and the ease of repair is also a distinct advantage. If the dentist should be deterred from the use of the
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continuous gum case by the objections voiced by D r. Hardy, in the hands of the careless patient even the simple vulcanite denture would be in a hazardous position. B e rt L. H oo p er , Lincoln, N e b r .: As Dr. H ardy states, there is a lack of apprecia tion on the p art of many dentists regarding the esthetic requirements of artificial den ture cases. T here is a brighter side to this situation in view of the fact that the dental profession is becoming more and more in terested in esthetics as applied to denture construction. W hether the dental profession wishes or not, it is going to be forced to produce better dentures from the esthetic standpoint, as the public is becoming more and more educated to appreciate good look ing and well cared for natural teeth, which, of course, makes them the more observant of artificial substitutes. T h e dentist who equips himself to appreciate and produce good esthetic results will find his services always in demand. Of necessity, in the past few years, much time has been spent on the mechanics of constructing comfortable and efficient dentures. W ith the knowledge and equipment accruing from this intensive work, the profession can produce dentures which are efficient and comfortable to the w earer. So intense has been the study of mechanics that, to some degree, we have lost sight of the esthetic requirements. It seems that it would be w orth while to the profession to apply diligently the knowledge that we have of mechanics and add to this all the possible information th a t is obtainable concerning the, esthetic requirements of the case. Those who have not indulged in an attempt to re produce in appearance a natural dentition or to study and apply a rt in denture construc tion have missed one of the greatest satis factions and joys that dentistry has to offer, second only to that which such service brings to the patient. T he sooner the hearers and
readers of this paper by Dr. H ardy take seriously to h eart his message and put it whole-heartedly into practice, the sooner the joys and rew ards of success will be realized. The following ideas are expressed, not in a sense of criticism, but rather as an additional suggestion. In mounting the n atural teeth, I take dentocoll impressions of the natural teeth before extraction; pouring these with some hard cast material. W hen the natural teeth are all removed, a dentocoll impres sion is taken of this cast. T he natural teeth are then placed in this impression and the mounting is completed. T he advantage of this procedure is that the natural teeth, if removed at intervals, may be kept in a solution until all have been extracted and then mounted. D r. H ardy has mentioned the difficulties encountered in the perplexing edentulous case, where no information is at hand regarding the natural teeth. It is only through the dentist’s observation and appli cation of knowledge gained thereby that sat isfactory esthetic results may be obtained; and I know of no better way to gain this knowledge than to imitate the natural teeth as nearly as possible whenever records of the natural dentition are available. It is only by this means that sufficient skill and ability may be obtained to assure satisfactory esthetic results in the edentulous case. To assure an esthetic result throughout, it is essential th at the base material imitate the appearance of gum tissue as nearly as pos sible. T h e phenol-resin compounds have proved most satisfactory in this regard, not only from the standpoint of esthetics, but also from the standpoint of comfort and ef ficiency. Looking beyond this paper of D r. H ardy’s, one can see a practice composed of many satisfied denture patients—patients who do not hesitate to smile or laugh, show ing teeth th at build facial character and facial personality.
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E F O R E enum erating or attem pting to describe the aids to esthetic con siderations w hich m ay be employed in th e construction of dentures, and w hich I hope to bring again to your a t tention, I shall endeavor to point out w h at I believe is a crying need fo r greater atten tio n to th e appearance of the appli ances th a t w e dentists construct. T h e w earers of dentures, according to my observations, fall into tw o groups as fa r as th e appearance of the teeth is concerned. T h e m ajo rity are w earing d entures w hich are n o t only obviously artificial, but, in m any cases, also posi tively grotesque looking. W e are forced to believe th a t the m en w ho construct such dentures take the easy w ay out, per haps leaving the m atters so vitally im p o rta n t to proper appearance entirely in the hands of a laboratory, and then persuading the patient to accept the den tures, unsatisfactory though he may know them to be. P atien ts w ho are w earing dentures of this type are not receiving tru ly professional service, and their teeth, even though they function creditably, can never be any g reat source of satisfaction to them , no r cast any credit on the prac titio n er w ho m ade them. O f course, some patients m ay in tim e become som ew hat accustom ed to an u n a ttractiv e appearance, accepting it as part *Read before the Section on Full Denture Prosthesis at the Seventy-Fourth Annual Session of the American Dental Associa tion, Buffalo, N. Y., Sept. 13, 1933. Jour. A .D . A ., A p r il 1933
of an inevitable b urden of those who w ear dentures, b u t there are m any sensi tive souls w ho have suffered considerable m ental agony, due solely to a realization of th e fact th a t th eir artificial teeth w ere indeed obviously artificial. A second, and I am sorry to state, much sm aller group of d en tu re w earers have been strong-m inded enough n o t to accept the m ediocre p roduct w hich has been foisted on th e m ore docile o r have been discrim inating or fo rtu n a te enough to select a p ractitio n er w ho w as not averse to p u ttin g at least some of his own handiw ork into the construction of his d e n tu re s; a m an w ho w as not content to pass a standardized, stereotyped prod uct along to his patient. T h is m an may have employed one or all of the aids and artifices w hich can be used to prom ote esthetic considerations, an d w ill have produced a result w hich m ay n ot be perfect in all cases, b u t w hich, in many, w ill be so n a tu ra l looking as to v irtu ally defy detection. I realize th a t, in m any cases, it is extrem ely difficult to achieve exactly the esthetic result th a t m ight be described as perfect, b u t I have found th a t the proper em ploym ent of the follow ing processes w ill do a g reat deal tow ard enabling the dentist to build in to his cases a degree of naturalness n o t to be achieved w ith o u t such aids. I t is my belief th at, in the vast m ajo r ity of cases, the tooth form, to o th a r rangem ent and tooth color w ith w hich
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H a rd y — E sthetics in D en tu re C onstruction N a tu re equips an individual blend w ell, and are generally harm onious w ith the oth er facial characteristics. T h erefo re, w hen w e are fo rtu n ate enough to have seen the n atu ra l teeth, w e had best take steps to register the appearance before the te eth are lost, and to this end w e employ photography. T h e m ost im portant picture to be taken is the one in profile, to register the facial contours and especially the lip positions, for it is proposed, in th e fin ished dentures, to build the lips out to the position th a t they originally occupied, and it m ight be difficult to achieve this result w ith o u t an accurate record as a guide. In m any cases, there has been a distinct closure of the bite, w hich is due to the loss of some of the posterior teeth, and it is found wise to open the bite w ith blocks of w ax or cotton rolls gripped betw een the rem aining posterior teeth before posing the patient fo r a profile picture, so th at, afte r the teeth have been removed, the photograph m ay be used for reference in building bite rim s to proper contour. P ictu re s taken of the fu ll face, both in a position of rest and w ith th e lips draw n back to show the teeth, may also be taken and w ill always serve as refer ence guides d uring the process of con stru ctin g dentures. A n article by B. L . H ooper gave me most of my ideas regarding the applica tion of photography to prosthetic w ork, and C . J . Stansbery1 has presented a profile enlargem ent m ethod w hich I have g ratefully adopted. A second invaluable aid in establishing esthetic values is the securing of proper preextraction models of the n a tu ra l teeth. O ne of these is taken w ith the bite1. Stansbery, C. J.: Functional Position Checkbite Technic, J.A.D.A., 16:421 (M arch) 1929.
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opening blocks used for the photographs in place, a piece of m odeling com pound, usually backed up by a strip of aircham ber m etal, being m olded over the labial surfaces of both the upper and low er teeth w hile th e teeth are in centric occlusion. A fte r this is chilled, removed from the m outh and poured in plaster, w e have in one m odel a replica of the visible surfaces of the an terio r teeth, the overbite, o verjet an d relative positions of the m an d ib u lar to th e m axillary teeth. I t w ill prove a distinct aid in assuring proper tooth arran g em en t in o u r dentures. A high-sided tra y filled w ith w arm beeswax is used to take an impression of the n a tu ra l te eth w h ile they are still in the m outh, and, afte r the teeth are ex tracted, they are set in position in this beeswax impression, and plaster poured about th eir roots to retain them . T h ese teeth are to be soaked in w a te r fo r a few days before w e construct the dentures, to restore th eir color, w hich w ill change if they are kept d ry ; an d th eir use as a guide w ill enable us to im itate alm ost exactly individual tooth form an d tooth color. W ith the afore-m entioned records, w e have secured invaluable aid to an esthetic result, and operators w ho fail to secure them , or th eir equivalent, not only place themselves u n d er a severe handicap by sacrificing the o p portunity to do so, b ut are guilty of som ething m ore th an casual oversight in neglecting an opportunity for serving th eir patients. In constructing dentures for cases in w hich w e have these records, teeth are selected from a stock mold, as n ear in form an d Golor to the n atu ra l teeth as possible. I t w ill, of course, be impossible to get exact m atches of both form and color, b u t the tooth form can be readily changed by grinding and the color can be altered by shading w ith m ineral stains.
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M y equipm ent fo r this w o rk consists of a furnace w hich, w ith a rheostat to control the heat, represents an investm ent of less th an $25. A few bottles of “ 1600” stain, some “ 1600 glaze,” a glass m ixing slab, some brushes and distilled w ate r constitute the rest of the equipm ent.
is to replace once occupied. T h is care in tooth form and to o th arran g em en t is expended only on the six or eight an terio r teeth, the teeth posterior to th e first bicuspids, of course, being placed in posi tions best suited to th e prom otion of stability in the denture. I t is wise now to check the resu lt in the m outh, to m ake sure th a t th e tooth form an d arrangem ent are satisfactory, and to m ake such modifications as may be necessary. W h e n these changes, if any are required, have been m ade, the next step is the use of the previously m entioned m ineral stains fo r coloring the teeth. T h e an terio r teeth are rem oved from the baseplate by w arm in g th e w ax a little, each to o th being carefu lly re moved. T h u s, a socket w ill be le ft in the w ax into w hich each to o th m ay be reset accurately w hen the next step is com pleted.
M a y w e suppose, now, th a t our prob lem is th e construction of a m axillary den ture to occlude w ith n a tu ra l low er teeth. T h e impression has been taken and the bites have been registered, the casts m ouiited on the a rticu la to r and the proper stock teeth selected, the next step being th e setting up of the teeth. W ith the casts supporting the p atien t’s extracted n a tu ra l teeth and the plaster model of the upper and low er teeth in centric occlusion as guides, I grind each porcelain to o th to proper size and shape, im itating in the porcelain enam el ir regularities, abraded and eroded areas and any deviations from perfect tooth sym m etry th a t it is deemed wise to repro duce. A s these teeth are ground, they are set up on the w ax baseplate of the m axillary cast, and by constant reference to the centric occlusion model, each a r ti ficial to o th is placed in exactly the same position th a t the n a tu ra l tooth w hich it
I t is essential th a t th e teeth be care fully cleaned before any staining is done, and to this end they are scrubbed w ith a stiff bristle brush and soap an d w ate r, a fte r w hich they are boiled in a strong solution of w ashing pow der an d w ater. T h is boiling removes any w ax o r grease w hich m ight resist the action of soap and w a te r only. I find it wise to exam ine the teeth w ith a glass before going fa rth e r w ith th e w ork, to m ake sure th a t the surface to be colored is really clean and free from specks, w hich m ig h t escape the eye w ith o u t th e use of m agnification. T h e actual application of th e stains used is very difficult to describe, b ut it is n o t of itself very difficult. W ith th e n a tu ra l extracted teeth as a guide for the colors to be used. I m ix a little of each color o r com bination of colors of stain on a glass slab, using distilled w a te r as a vehicle, and, holding th e to o th in a pair of cotton pliers, paint th e colors on
I should like to go into detail reg ard ing th e coloring of stock teeth w ith m ineral stains, fo r I believe it to be one of the m ajo r aids fo r producing n atu ra llooking artificial teeth. T h e idea is by no m eans new . L aw rence B aker, of Boston, w ro te on the subject tw enty-five years ago, and did beautiful w o rk w ith stains a t th a t tim e. T od ay , since w e have at hand such excellent and, at the same time, very inexpensive equipm ent for the purpose, it seems strange th a t this w o rk is not m ore generally done, as it enables the operator to produce results in denture construction th a t are scarcely obtainable in any other w ay.
H a rd y— E sthetics in D e n tu re Construction the tooth surface. T h e furnace having been previously brought to the proper heat, I hold the tooth up before the open door fo r a few seconds to fix th e colors a fte r they have been applied, and then set th e tooth on a silex covered fire clay tra y w hich is of sufficient size to ac com m odate six teeth. T h e tray, w ith the teeth so laid upon it th a t they do not touch each other, is introduced ju st inside the door of the furnace, left there for tw o or three m inutes, and then p u t inside the furnace and the asbestos block door p u t into place. F rom three to five m in utes is tim e enough to fire the colors, a fte r w hich the .tray can be removed from th e furnace, carefully protected w ith a cover to prevent d rafts from checking the porcelain and allow ed to cool. A fte r the teeth are cooled, the glaze is painted on in a generous coating. T h is glaze is tran sp aren t and is not to be con fused w ith some of the higher fusing glazes w hich, if applied in a heavy coat ing, tend to w ard opacity, and produce w h ite areas. In applying the glaze, w hich is a pow der and is m ixed w ith distilled w a te r as a vehicle, it is not absolutely necessary to have an even coat applied all over the surface to be glazed, for, d u rin g the firing, it seems th a t the coat ing evens itself o u t nicely. T h e teeth are now fired a second tim e in exactly the same w ay th a t they w ere w hen the stains w ere fused, and, after they are cool, w e find th a t the stock teeth have taken on a very life-like ap pearance, although they are sometimes a trifle too shiny. T h is high glaze m ay be reduced to a ra th e r d ull gloss by holding the glazed surface, liberally covered w ith w et pumice and kept continually so covered, against a rubber w heel m ounted on the lathe. W h e n this too shiny sur face has been reduced to a ra th e r satin finish, it w ill be seen th a t application of
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the heavy coat of th e glaze over the underlying stains gives an effect of depth of color, w hich is extrem ely life-like. F o r some years, I had been using high fusing stains, w ith an overlayer of 1,700 degree glaze, b u t the m ethod here briefly described w as suggested to me by H u b e rt K ohrm an, of D anbury, Conn., and it gives b etter results th an I ever achieved w ith the higher fusing glazes employed in a sim ilar m anner. I tru s t th a t this technic for coloring stock teeth w ill not seem so tim e-con sum ing as to preclude its use. T h e m ethod I have often seen attem pted of using m ineral stains on u n altered stock teeth over the original glaze is such an obvious subterfuge th a t it may ten d to accentuate, ra th e r th an conceal, the a rti ficiality of a prosthetic appliance, an d I w ould ask th a t those of you w ho have seen stains so employed, and w ho have therefore judged th eir use as of dubious value, give them an o th er try , using the m ethod here outlined, and I believe you w ill find in them a w eapon fo r com bating obvious artificiality w hich w ill serve you and your p atients m ost creditably. T h is paper has so fa r dealt only w ith the handling of those cases in w hich efforts are m ade to supply a patient w ith teeth w hich are in appearance very simi la r to his n a tu ra l o n es; th e com paratively simple m a tte r of faith fu lly im itating the m ost visible p arts of the n atu ra l d en ti tion. T h e task of rebuilding a m outh w hen I have never seen the n atu ra l teeth is to me m uch m ore of a problem. In such cases, I find th a t considerable help may often be derived from a ju d i cious use of the fact of fam ily resemblance. A w om an, perhaps 60 years of age, w ea r ing unsuitable dentures applies for new ones. I f inquiry should reveal the fact th a t this w om an has a d au ghter whose facial characteristics are like her
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m o ther’s, I feel justified in copying the tooth form and tooth arrangem ent of the d au g h ter’s n atu ra l teeth w hen m aking artificial ones for the m other. T o avoid the distinctly incongruous effect of young teeth in an older individual, the precau tion is of course taken of selecting a basic shade w hich w ill be consistent w ith the years and com plexion of the patient, and the teeth are properly aged by g rin d ing th e incisal edges to sim ulate w ear and the necks to im itate erosion, and by artistically shading the teeth w ith m in eral stains. I find th a t the factor of fam ily resemblance may prove a very distinct aid in puzzling cases w hen the m ore direct guidance of a few rem aining n a tu ra l teeth is lacking. In th a t great num ber of cases in w hich th ere are no n atu ra l teeth rem aining nor is assistance from a m em ber of the fam ily in obtaining proper tooth form and a r rangem ent available, J . L eon W illia m s’ m ethod of selection w ill of course prove o u r only salvation. I believe th a t in ap plying this happily discovered form ula, care should be taken to select teeth of adequate size, for, in observing the ap pearance of m any dentures, I have come to the conclusion th a t one of the most common violations of the esthetic precept is the use of teeth too sm all for the case, and it is often an e rro r w hich at first glance brands the restoration as spurious. W hen the proper teeth have been selected, the task of arran g in g them in a n a tu ra l looking set-up can be arrived at, as far as I know, only by a tria l and erro r method, follow ing the arch form as a guide, and avoiding w here possible too g reat a sym m etry in the arrangem ent. Sometimes a patient likes to rem em ber th a t her n atu ra l teeth w ere very regular, and w ill insist on a ra th e r sym m etrical arrangem ent of the artificial teeth. If I m ust bow to the p atien t’s wishes in the
m atter (an d I certainly try to have the patient believe th a t I am open to sug gestions from h im ), I find th a t by properly g rin d in g and coloring the in dividual teeth, th a t is to say by m aking the individual teeth m ore o r less asym m etrical, I can arran g e them in an even set-up and still entirely avoid th at deadly look of a row of porcelain blocks w hich brands so m any dentures as a rti ficial. T h e introduction of a gold filling or inlay may be a g reat help in breaking the m onotony of a sym m etrical set-up. F illings of a com pound type are p refer able: on th e an terio r teeth, mesio-incisal or disto-incisal fillings; on the bicuspids, mesioclusal types. T e e th w hich are to receive these fillings are colored slightly bluish aro u n d the m arg in of th e filling, in im itation of th e shadow cast by the gold th ro u g h the enamel, o r even the tiny leakage often seen in fillings w hich have been some years in place. Some of the rubber substitutes w ith w hich the profession is now experim ent ing and w hich seem to be im proving as they are used and perfected w ill, w e hope, prove of great aid in those high lip line cases in w hich, up to th e present time, it has been extrem ely difficult to achieve anything like a proper esthetic result. I have heard prosthetists sug gest th a t th e use of long teeth in such cases to avoid show ing any rubber w as a w ay out of th e difficulty, b u t this cure in practice often proves w orse th a n the show ing of vulcanite. I have also seen the problem m et by placing th e denture so fa r up u n d er the lip th a t w hile the patient tru ly showed no rubber, neither did he show any teeth. A ll together, there has been b ut one answ er to these cases, and th a t is the rath e r expensive expedient of a continuous gum denture, and even this solution is n o t an ideal one,
H a rd y— E sthetics in D en tu re C onstruction for the w eight and fragility of the den tu re m ight be nearly as g reat a draw back as its expense. 1 have had considerable success in these cases by em ploying one of the phenol-resin com pounds as a veneer over an underlying rubber base, in this w ay securing a strong foundation, w ith a n a tu ra l looking gum , w hich, if it dete riorates, may be quite readily replaced w ith o u t disturbing th e body of the den tu re. T h e veneer m ust be fairly heavy to look w ell, as otherw ise the underlying rubber tends to show thro u g h th e facing and destroy the artistic effect. T h is m ethod is, of course, a fra n k compromise, but it is nevertheless a distinct aid in achieving a lifelike im itation of n atu ra l gum w here vulcanite rubber w ould not only m ar but, w e m ight say, nullify all the good effects achieved by a proper a r rangem ent and coloring of the teeth themselves. P erhaps the various steps in technic herein enum erated as aids to esthetic re sults in denture w ork m ay seem to some superfluous, but I have learned from sad experience th a t the task is difficult w hen every means possible is employed to bring about a proper result, and th a t I cannot therefore afford to ignore or neglect any aid, artifice, means or m ethod w hich w ill lift the product of my handi w ork out of the limbo of false teeth, and make it a factor of prim e im portance in restoring to the patient his n atu ra l appearance. 2 East Fifty-Fourth Street. DISCUSSION M i l t o n Cohen, N e w Y o rk C ity.: Dr. Hardy stresses the case of the patient who has some of his anterior natural teeth, a type of case which is not nearly so common as the wholly edentulous one. T he skill of the dentist is more heavily taxed with the latter type, and it is this patient who must be pleased far
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more often than the one who has some of his own teeth left. Usually, staining of artificial porcelain teeth is done against the patient’s wishes, and is is finally accepted only after a trial in the mouth of the patient, and then only if it is not overdone. It is difficult to overcome the natural antipathy of the pa tient to a truthful reproduction of his own teeth where fillings and decay are apparent when it is his desire to improve his appear ance with a newer, cleaner and better look ing arrangem ent of teeth in a denture, but, for all that, a light and not too obvious staining of the teeth is very desirable and the use of stains should be encouraged by the dentist. I take exception to only one statement which Dr. H ardy has made, that concerning the continuous gum case. He practically admits that this type of restora tion most closely approaches the ideal, and then dismisses its use in an off-hand manner because of the expense involved. If it is agreed that, in addition to the restoration of the natural functions, the construction of a continuous gum case offers greater esthetic possibilities than any other prosthetic product now at the command of the dentist, the ques tion of expense should be given the least amount of consideration, it any at all. T he advantages of the continuous gum case over the vulcanite and the other resinous substitutes by far outweigh the objections of expense. T he very desirable reaction of the tissues to the platinum base and the smooth porcelain surface; the therm al changes which are easily registered on all the underlying soft tissues; the true sense of taste that is communicated to the palate; the absolute cleanliness of the denture from a hygienic standpoint and freedom from attacks from the products of bacterial reaction on the platinum and the porcelain, and the ease with which it can be kept in a state of cleanliness are advantages accruing from the use of the continuous gum case. Dr. H ardy’s objection to its weight is over come by the use of a lighter gage platinum base; for example, No. 32 or No. 36, which has been employed with great success, and, as to the fragility of the material, instruc tions to the patient to use due caution while cleaning the denture will obviate any dif ficulty from that source. A fracture of the material while in function in the mouth is of rare occurrence and the ease of repair is also a distinct advantage. If the dentist should be deterred from the use of the
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continuous gum case by the objections voiced by D r. Hardy, in the hands of the careless patient even the simple vulcanite denture would be in a hazardous position. B e rt L. H oo p er , Lincoln, N e b r .: As Dr. H ardy states, there is a lack of apprecia tion on the p art of many dentists regarding the esthetic requirements of artificial den ture cases. T here is a brighter side to this situation in view of the fact that the dental profession is becoming more and more in terested in esthetics as applied to denture construction. W hether the dental profession wishes or not, it is going to be forced to produce better dentures from the esthetic standpoint, as the public is becoming more and more educated to appreciate good look ing and well cared for natural teeth, which, of course, makes them the more observant of artificial substitutes. T h e dentist who equips himself to appreciate and produce good esthetic results will find his services always in demand. Of necessity, in the past few years, much time has been spent on the mechanics of constructing comfortable and efficient dentures. W ith the knowledge and equipment accruing from this intensive work, the profession can produce dentures which are efficient and comfortable to the w earer. So intense has been the study of mechanics that, to some degree, we have lost sight of the esthetic requirements. It seems that it would be w orth while to the profession to apply diligently the knowledge that we have of mechanics and add to this all the possible information th a t is obtainable concerning the, esthetic requirements of the case. Those who have not indulged in an attempt to re produce in appearance a natural dentition or to study and apply a rt in denture construc tion have missed one of the greatest satis factions and joys that dentistry has to offer, second only to that which such service brings to the patient. T he sooner the hearers and
readers of this paper by Dr. H ardy take seriously to h eart his message and put it whole-heartedly into practice, the sooner the joys and rew ards of success will be realized. The following ideas are expressed, not in a sense of criticism, but rather as an additional suggestion. In mounting the n atural teeth, I take dentocoll impressions of the natural teeth before extraction; pouring these with some hard cast material. W hen the natural teeth are all removed, a dentocoll impres sion is taken of this cast. T he natural teeth are then placed in this impression and the mounting is completed. T he advantage of this procedure is that the natural teeth, if removed at intervals, may be kept in a solution until all have been extracted and then mounted. D r. H ardy has mentioned the difficulties encountered in the perplexing edentulous case, where no information is at hand regarding the natural teeth. It is only through the dentist’s observation and appli cation of knowledge gained thereby that sat isfactory esthetic results may be obtained; and I know of no better way to gain this knowledge than to imitate the natural teeth as nearly as possible whenever records of the natural dentition are available. It is only by this means that sufficient skill and ability may be obtained to assure satisfactory esthetic results in the edentulous case. To assure an esthetic result throughout, it is essential th at the base material imitate the appearance of gum tissue as nearly as pos sible. T h e phenol-resin compounds have proved most satisfactory in this regard, not only from the standpoint of esthetics, but also from the standpoint of comfort and ef ficiency. Looking beyond this paper of D r. H ardy’s, one can see a practice composed of many satisfied denture patients—patients who do not hesitate to smile or laugh, show ing teeth th at build facial character and facial personality.