Complete dentures

Dayton Dunbar Krajieek, D.D.S.*

Veterans Administration Center, Wadsworth., Kan.

T he preservation
every individual.
of a normal appearance is vital to the emotional well-being of
This is increasingly evident in todays’ society where the emphasis
on youth and a youthful appearance has grown to be a byword for the advertising
industry. The clothes we wear, the cars we buy, and even the soft drinks we pur-
chase are often marketed for the “young at heart.” It is regrettable that the standard
of facial appearance for the average denturr wearer often is srt by a laboratory
technician who never sees the patient.’
Unfortunately, the factors which govern the restoration of natural appearance
for edentulous patients frequently are discussed but just as frequently are mis-
understood. This is not surprising when one examines the disruptive elements which
involve the patient’s entire maxillofacial complex as a result of becoming endentu-
lous. Solutions are not easy nor are they automatic. It is only through a practical
knowledge of the basic scienres plus the applied creative and artistic ability of
dentists that answers may be found.
A discussion of pertinent biologic factors will be presented, and the factors
will be interpreted as they apply to the clinical aspects of prosthodontics. The areas
to be discussed are ( 1 j alveolar bone, (Z‘r skin, (3) muscle physiolo‘gy, (4) ton<gue,
and (5 ‘I clinical application.

ALVEOLAR BONE
The status of the residual alveolar bent% must be our prime consideration since
this tissue provides the basic: support for complete dentures. Following the loss of
natural teeth, the constant and progrrssivc resorption of the residual ridges is a
common occurrencc.z The placement of a denture base may seem to hasten ridge
resorption, but research rbvidence indicates that resorption of bone is a complex bio-
physical process and mnnot be cornl~lrt~ly controlled by denturr procedures.”

Read before the .4cadcmv of Denture Prosthetics in New Orleans. La.

*Chief, Dental Service, Associate Clinical Profrssor of Prosthodontics, University of Mis-
souri at Kansas City, School of Dentistry.

122
 Dental art in prosthodontics 123

Fig. 1. As a result of bone loss in an edentulous mouth, the individual’s facial features are
dramatically altered. Because the patient is not advised that these changes occur normally,
he fails to appreciate the need for prosthetic assistance in the form of periodic prosthetic
recall.

From the point of view of the appearance phase of complete denture construc-
tion, two significant prosthetic facts become evident. First, bone resorption of the
residual ridge following the loss of the natural teeth is a common clinical finding.
The rate of this resorption and the amount of bone loss vary among individuals.
They do not remain constant for a given patient at different time periods. As a
result of bone loss in endentulous mouths, the individual facial features are dramat-
ically altered. Second, when a denture is constructed to restore these lost parts, the
artistic achievement, if successful, can be only transitory.
Too often the patient is not advised of these changes which will most certainly
occur. Consequently, he does not feel or see the need to seek prosthetic assistance
as resorption continues (Fig. 1) . This further justifies and points to the need for
periodic recall, because some patients tend to develop what Geiger* terms “sight
tolerance” for their dentures.

*Personal communication: Dr. E. C. Kelly Geiger, Washington University School of

Dentistry, March 14, 1968.
 J. I’,o\. Dent.
Frh ,,a,~. 1969

SKIN
Perhaps no organ in the body advertises agin <gmore noticeably and more quickly
than dots the skin. Wrinkles, baldness, and graying signify age even to a child.”
C:hangw in the skin may be attributed to (1) the normal aging process, (2)
hereditary predisposition to skin degeneration, and (3) loss of the natural teeth.
Histologically, the changes of the skin are primarily atrophic in nature. Such
alterations include progressive loss of contractilityz fragmentation, and basophilic
degeneration of the yellow elastic fibers and their replacement by inelastic collage-
nous tissue. ,4s a result of atrophy of the subcutaneous fatty tissue and reduction in
rnuswlar II~XS, the overlying skin, having lost its elastic recoil, can no longer adapt
itsr1f to the diminished volume it covers; consequently it gravitates to the lower
part of the face. In the folds, however, the skin remains attached. and it is in these
lines of adherence that the skin hangs and produces the wrinkles.”
Unfortunately, the aging wrinkles about the mouth cannot be erased by the
plastic surgeon as \VC have been lead to believe.” Greater responsibility is placed
. .
upon the prosthodontlst to posltlon teeth for each patient and to effect maximum
support of the fare. both in repose and in function.

MUSCLE PHYSIOLOGY
Anatomically, the muscles of facial expression have their origin in bone, they
converge at the corners of the mouth, and they blend into the orbicularis oris
musc~1c. Since this muscle is devoid of bony or&gin, it gains its support almost en-
tirely from the teeth (natural or artificial substitutes) and from alveolar bone or
denturc-base material. The upper and lower lips are composed of interlacing and
continuous fibers of all the upper and lower muscles of facial expression as well as
thr* orbicularis oris muscle. There is a variance between the right and left side as
to the number of muscle fibers involved and as to the depth of their insertions; as
Sicher’ points out, this muscle operates as a unit in function, but anatomically.
it is not a unit. The varied composition of this complex orbicularis oris muscle,
from one side to the other. accounts for the varying amounts of natural or internal
support that are evident in some patients without complete dentures.

THE TONGUE
‘l‘hc most influential and powerful muscle of the oral cavity is the tongue. In
truth, complete dentures must function between the musculature of the lips extra-
orally and the tongue intraorally. The tongue is made up of intrinsic and extrinsic
muscles, and it is a combination of the t~\o in function kvhich accounts for its great
mobility and versatility.
Although the swallo\ving reflex is established at birth as a synchronized activity
essential to life, it is subject to constant alteration induced by the changing condi-
tions of the orofacial structures. Merely covering the palate lvith a denture base
requires an alteration in thr thrust pattern of the tongur.
The progressi\re loss of natural teeth, failurr to place artificial teeth in natural
positions, changes in the form and size of maxillary and mandibular ridges due to
resorption, and changes in vertical dimensions of occlusion collectively and indi-
vidually contribute to alterations in size and shape of the oral cavity. The altera-
tions disturb precise coordination in function betueen the lips and tongue, produc-
2!%~‘: Dental art in prosthodontics 125

ing abnormal tongue-thrusting habits, dislodgment of the denture bases, and a dis-
torted facial appearance.

CLINICAL APPLICATION
In patients with severe residual alveolar ridge atrophy, the outline form of the
occlusion rims may be physiologically contoured by muscle activity. This aids in
determining the tooth location and lip support. Wax occlusion rims are formed
and attached to stable acrylic resin bases. The tentative vertical dimension of occlu-
sion is established with a combination of all methods at our disposal. Interocclusal
centric relation records are made with a plaster recording material, and casts are
mounted on the articulator by means of a face-bow. The upper wax occlusion rim is
reduced from the buccal, labial, and lingual sides, and a thin hard section of wax

Fig. 2

Fig. 3

Fig. 2. A cold-curing resilient denture-base material is mixed to a thick consistency and is

placed in the anterior part of the palate of the maxillary temporary base. While the material
is setting, the patient is instructed to close lightly and swallow. The anterior thrust pattern
of the tongue, peculiar to that patient, will be recorded during normal swallowing. The
tongue will now aid in stabilizing the maxillary base and will discourage the tongue from
pushing the base forward during the remainder of the procedure.
Fig. 3. The same type of resilient denture-base material as used in Fig. 2 is placed on the
labial and buccal surfaces of the wax occlusion rim on the maxillary temporary base. The
ideal flow and setting properties of the recording medium allow the lips to determine the
physiologic outline form of the dental arch at a previously determined vertical dimension of
occlusion.
 126 Krajicek J. Pros. Dent.
February, 1969

is maintained to preserve the occlusal vertical dimension. An auto-cure resilient

denture-base material* is Inixed to a thick consistency and is placed in the anterior
palatal part of the maxillary temporary base. With his head in an upright position,
the patient is instructed to close lightly and to swallow. This is continued for three
or four minutes, and the base is examined. An anterior thrust pattern of the tongue,
peculiar to that patient in normal swallowing, will be recorded in the soft resin
(Fig. 2). This procedure will permit these reflexes to be repeated during the func-
tional forming of the remainder of the rims (Fig. 3). The tongue will now aid in
the stability of the bases and will discourage anterior shunting of the upper occlusion
rim. Because of the ideal flow of the recording media and because of its setting
properties? the lips are not restricted in activity when forming the labial contours.
Furthermore; a muscle balance is achieved between the lips and the tongue by
allowing the tonswe to consistently return to a preformed area. Artificial teeth
then may be arranged in the laboratory to conform to the confines of a plaster
matrix poured to the physiologic outline form.

TEMPORARY BASES
Accurate temporary bases of acrylic resin are routinely fabricated on the master
casts by the sprinkle method. The use of an auto-cure resilient acrylic resin+ in the
undercut areas enhances accuracy and stability in the mouth while preventing
injury to the casts during removal of the temporary bases. The consistent use of
these rigid, stable bases has proved to be worthwhile, even to appearance.8 Neither
an intraoral record or procedure related to appearance nor the arrangement of
anterior teeth can be more accurate than the bases upon which they are made.

OCCLUSAL VERTICAL DIMENSION

Establishing an acceptable occlusal vertical dimension is fundamental to ac-
ceptable appearance, and yet there is no infallible method for determining a precise
amount of interocclusal rest distance. The stretch reflex action and the propriocep-
tive mechanism in muscles and in ligaments of the temporomandibular joints
contribute to an acceptable mandibular position for the patient.s The final vertical
dimension of occlusion must never be determined by pleasing facial proportions
alone, for this would lead to frequent intrusions upon the vertical dimension of
rest. A combination of all accepted methods (that is, phonetics, appearance, facial
measurements, pre-extraction records, physiologic requirements, and sound pro-
fessional judgment and experience) is essential. This part of complete denture
construction can be so challenging that it is critically evaluated again after the teeth
have been arranged on the temporary bases. It should be understood that some de-
gree of interocclusal rest clearance must &rays exist and must be intentionally
incorporated in the dentures.

THE TEETH
Tooth placement with its t\zo components, position and alignment, is one of the
most important factors governing a natural appearance of the mouth and face. Un-

*Tru Soft, Harry J. Bosworth Company, Chicago, III.

jDura Base, Reliance Dental Mfg. Company. Chicago, Ill
 Dental art in prosthodontics 127

fortunately, the selection and arrangement of artificial anterior teeth are too often
delegated to the dental laboratory technician since this has been considered to be
a purely mechanical aspect of our procedure. Tooth placement is biomechanical
in nature, for it governs lip support and is responsible for the firmness of muscle
tone and for muscle activity of the face.
Obviously, teeth must be chosen before they are arranged. Tooth selection,
therefore, will be considered first. The three counterparts of tooth selection (dimen-
sion, color, and form) will be discussed in order of their impact to the completed
anterior dental composition.

SELECTION OF ANTERIOR TEETH

Dimension. Dental art is creative and complex, because the dimension, form,
and related tissues of the orofacial region have been lost by the patient. Techniques
of tooth selection, directed toward choosing teeth of appropriate sizes, evolved as
a result of attempts to establish guides as an improvement upon the “hunt and pick”
method.
The mesiodistal dimension of anterior teeth is most important, for when anterior
teeth are too small, complete dentures fail to convey realism. Since tooth width is
dependent upon proportions of the edentulous face, the studies of HouselO were
found to be useful. In comparing the harmony of face and teeth in 555 living sub-
jects, House and LooplO found that the greatest bizygomatic width of all upper
central incisors was approximately one sixteenth the width of the face. A face-bow
is used as a caliper for this measurement, and then, the numerical calculations are
made. These two teeth serve as the key to the dental composition.
Appropriate breadth deviations in selecting the supporting teeth (lateral inci-
sors and cuspids) can produce the illusion and effect of either harshness or gentle-
ness.ll This process of tooth selection is an attempt to correlate the best tooth sizes
with each edentulous face in a reliable, easy-to-use method (Fig. 4).
Color. In selecting shades of individual artificial teeth, some type of shade guide
is used. Hardy*’ wisely stated that “a single natural central incisor is a better guide
for tooth selection than all the mold guides ever made.” This applies equally to
shade or tooth color.
Color has three dimensions: ( 1) hue, (2) brilliance, and (3) saturation. From
the color spectrum (that is, red, yellow, green, and blue), we determine hue. Most
shade guides today utilize yellow as the predominate color; the others are of only
minor importance.
Brilliance in color involves the degree of lightness or darkness. The more nearly
white an object is, the more brilliant it is considered to be. Brilliance is the impor-
tant changing quality in teeth, for as people advance in age, the teeth tend to be-
come darker or less brilliant.
Saturation refers to the amount of hue in a color. Since only yellow is of im-
portance, saturation refers to the amount of yellow found in each tooth.
Shade guides have an assigned number to each tooth according to variations
in color of gray and yellow. Shade 61, for example, generally has the least satura-
tion and the most brilliance.
In complete denture construction, it is unimportant that a specific numerical
shade for artificial teeth is selected; however, it is important that teeth of different
128 Krajicrk J. Pros. Dent.
February. 1969

Fig. 4. Dental compositions are best de&cd by the dentist when he selects artificial teeth to
harmonize with the dimensions of the fare.

shades be used within the composition. ‘There should also be a delicate mingling
of shades within each tooth, as is contributed to natural teeth by Nature.
If we purposedly avoid discords of color between teeth and face, controversies
regarding shade for his patient can usually be resolved by the dentist. Tooth place-
ment has a definite influence on the illusion of lightness or darkness in tooth shade,
SO patient’s comments arc reserved for thr appointment visit when the completed
anterior composition has been devised.
Form. The artistic ability of the prosthodontist is more meaningful v\-hen an
arrangement of natural anterior teeth is copied than when he merely selects a tooth
mold. As a tooth rotates or changes in its vertical inclination, it seems to present a
different outline form to the rye. Three srts of the same mold of teeth arranged to
a square, a tapering, and an ovoid aligmnent, as pointed out by NeIson,13 would
appear as three entirely different sets of teeth (Fig. 5). Providing patients with
actual reproductions of natural teeth by hand molding is an ideal method of ful-
filling the demands of tooth form. Regardless of whether stock teeth or hand-
molded teeth are selected, they must bc considered as only the raw material of
the teeth to be used. The prosthodontist is obligated to recontour and reshape each
individual tooth for the part it will play in the completed composition.
 Dental art in prosthodontics 129

Fig. 5. Three sets of the same mold of artificial teeth arranged to square, tapering, and ovoid
alignments appear to have been made from three entirely different molds of teeth.

PLACEMENT OF ANTERIOR TEETH

Position. In the absence of physiologically contoured occlusion rims, the final
positioning of the anterior teeth must be done by the dentist in the presence of the
patient. The size, the color, and the outline form may appear to be ideal, but until
the teeth are positioned for correct support of the cheeks and lips, the effect of
naturalness is not achieved. Both the vertical level and the labiolingual positions
must be determined in order to restore normal lip action and to prevent a loss of
the vermillion contour of the lips. The patient is asked to stand, walk, speak, smile,
and engage in the many activities of facial expression. Thus, the anterior teeth wilI
be positioned by the dentist a tooth at a time. These teeth will be tested phonetically
with the “f,” ‘rv,J’and “th” sounds, and will be carefully correlated with the lower
lip and the tongue during speech.
If any one guide predominates for achieving a natural appearance, it is that
anterior teeth appear separate and distinct from one another. There must be obvious
indications of inter-proximal embrasuresll (Fig. 6) .
NelsonX3 classified arch forms as square, tapering, and ovoid according to the
130 Krajicck 1. Pros. Dent.
pebl uary, 1969

Fig. 6. There must be obvious indications of embrasures between the teeth in the anterior
maxillary composition if the teeth are to have a natural appearance.
Fig. 7. Dental art must be purposely and carefully incorporated into the treatment plan by
the dentist. This is accomplished with appropriate tooth forms and by positioning them in
a natural arranaemrnt.

vault form of the maxillary arch, and he gave characteristic tooth positions for
each. The vault, being relatively stable, serves as a reliable guide. Accordingly, the
vault assumes a broad and shallow shape in the square arch, while the teeth arc
set straight up and down. The tapering arch usually has a high vault with an
inverted V-shape. The anterior teeth slant forward, and the central incisors tend
to overlap. In the ovoid arch, the vault is of medium height and is rounded, while
the anterior teeth slant inward with the cervical end of the tooth being mom prom-
inent than the incisal edges. Examinations of dentitions and casts of natural teeth
indicate that these positional arrangerncnts arc surprisingly consistent. Because the
guides are flexible, they are also of help in achieving our goal.
Alipzment. In rotating teeth or in “breaking” their alignment, typical inclina-
tions found in dentitions must bc follolved. This necessitates copying the arrangc-
ment of teeth in a cast (or casts) of natural teeth. The maxillary lateral incisor
teeth generally have the most predominant irregularities. If them is one key to
producing natural appearing replacements through tooth alignment, it is asymme-
try. Individual irregularities are introduced in accordance with the patient’s desires,
but these rotational positions must not he contrary to those created by Nature.

SUMMARY
Dental art does not occur automatically. It must be purposely and carefully
incorporated into the treatment plan by the dentist (Fig. 7) This artistry strives
to soften the marks imposed upon the fact by tiuw and enables people to face their
world with renewed enthusiasm and c~onfidcnc~c.
Prosthodontics in this area truly involws much mom than mechanics. Bone
resorption of the residual alveolar fmoccssrs, for exarnple~ holds special interest for
our specialty since the ever-changin,. cr ridqrs I provide support for dentures. Very
Volume 21 Dental art in prosthodontics 131
Number 2

little is known about it, except that it does occur. Studies concerning the repair
of alveoli after tooth extraction fail to examine area after bony repair is considered
to be complete. We do not know how the resorptive process takes place in the
endentulous ridge or how soon it is initiated after tooth loss.
Perioral wrinkling and creasing of the angles of the mouth are of major concern
to some of our endentulous patients. Plastic surgery will not solve these problems
for us, as we may have thought in the past. We do know that it is not necessary, or
even desirable, to erase these facial lines completely through prosthodontic therapy,
for then the lower third of the face would be in complete disharmony with the rest
of the face.
The anatomy and neurophysiology of the maxillofacial complex identify the
face of each person as an individual human being. We must develop a better under-
standing in order to continue to serve the needs of our edentulous patients.
Dental art, unfortunately, has a limited life-span. It is extremely important that
both the dentist and the patient understand this concept because the background of
living tissue which provides the framework for dentures is constantly changing.
Dental art can provide a natural appearance to the orofacial regions and can
harmonize the appearance of the lower third of the face with the total facial ap-
pearance. This is accomplished with appropriate tooth forms positioned in natural
compositions.
The importance of dental art lies in the meaning of this statement: “My physi-
cian keeps me alive but my dentist makes my life worth living.”

References
1. Hughes, G. A.: Discussion of “Present-Day Concepts in Complete Denture Sertiice,” J.
PROS. DENT. 10: 39-41, 1960.
2. Atwood, D. A.: Some Clinical Factors Related to Rate of Resorption of Residual Ridges,
J. PROS. DENT. 12: 441-450, 1962.
3. Ortman, H. R.: Factors of Bone Resorption of the Residual Ridge, J. PROS. DENT. 12:
429-440, 1962.
4. Lewis, G. K.: The Surgical Treatment of Wrinkles, Arch. Otolaryng. 60: 334-341, 1954.
5. Maliniak, J. W.: Is the Surgical Restoration of the Aged Face Justified? Indications-
Method of Repair-End Results, Med. J. & Rec. 135: 321-324, 1932.
6. Fomon, S., et al.: Aging Skin, a Surgical Challenge, Arch. Otolaryng. 61: 554-562, 1955.
7. Sicher, H.: Oral Anatomy, St. Louis, 1952, The C. V. Mosby Company, pp. 180-181.
8. Krajicek, D. D.: Natural Appearance for the Individual Denture Patient, J. PROS. DENT.
10: 205-214, 1960.
9. Lytle, R. B.: Vertical Relation of Occlusion by the Patient’s Neuromuscular Perception,
J. PROS. DENT. 14: 12-21, 1964.
10. House, M. M., and Loop, J. L.: Form and Color Harmony in the Dental Art, Mono-
graph, Whittier, Calif., 1939, M. M. House, p. 17.
11. Frush, J. P., and Fisher, R. D.: Introduction to Dentogenic Restorations, J. PROS. DENT.
5: 586-595, 1955.
12. Hardy, I. R.: Problem-Solving in Denture Esthetics, D. Clin. North America, pp. 305-
320, July, 1960.
13. Nelson, A. A.: The -4esthetic Triangle in the Arrangement of Teeth: Face Form, Tooth
Form, and Alignment Form, Harmonious and Grotesque, Nat. D. A. J. 9: 392-401, 1922.

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