The International Journal of Periodontics & Restorative Dentistry

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Classification of Altered Dental

Esthetics

Howard B. Kay, DDS* Dentistry has always been subject to

therapeutic trends that tend to
dominate the subject matter of pro-
fessional meetings and the dental
Clinical procedures designed to reestablish the idealized framework for the literature. During each of these
achievement of optimal esthetic restorative results have been frequently report- trends, the profession generally
ed. Yet complex cases, where remarkable improvements of esthetic appearance applies considerable focus on the
are achievable in spite of preoperative conditions, are infrequently presented subject, fostering enhancements,
because the presentation standards appear to be set for idealized situations. If a research, and broadened applica-
classification system that reflects dental esthetic compromises and ideals existed, tion of the prescribed methods as
cases could be categorized accordingly, and realistic expectations could be
well as expansion of the scope of
applied to assess the effectiveness and results of a course of therapy. Considering
associated modalities. Today, there
that there is not currently a published classification system to this end, it is the
has emerged a focus on esthetic
purpose of this article to tender a classification of altered dental esthetics.
dentistry centered on the ability of
(Int J Periodontics Restorative Dent 2002;22:85–94.)
the clinician and technician to recre-
ate the appearance of the natural
dentition with extraordinary ele-
gance. Research, technology, and
innovation have fostered clinical
procedures that are intended to re-
establish the proper environment
for the recreation of optimal restora-
tive esthetics. There has been a
focus on the surgical disciplines and
orthodontics for both general as
*Visiting Adjunct Associate Professor, Department of Graduate well as implant prosthodontics. This
Prosthodontics, College of Dental Medicine, Nova Southeastern no doubt has been an important
University, Ft Lauderdale; and Private Practice Limited to Prosthetic phase in the achievement of quality
Dentistry, West Palm Beach, Florida.
dental esthetics. There are demon-
*Reprint requests: Dr Howard B. Kay, 2521 North Flagler Drive, West strated capabilities and high stan-
Palm Beach, Florida 33407. dards for quality dental esthetics, if

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the idealized esthetic environment is
reestablished.
Such an idealized esthetic envi-
ronment is one where the patient’s
dentoalveolar complex is intact and
demonstrates characteristics that are
in harmony with the “framework” of
the esthetic dental composition.1
The components of the framework
include, but are not limited to, the
following.
The horizontal references are
lines that ideally are parallel to the
horizontal plane. Primarily, they are
the interpupillary line, incisal plane,
gingival margins, and maxillary
occlusal plane. There are also acces-
sory lines that include the ophriac,
commissural, and interalar lines.
Other horizontal references include
the lip lines that are assessed in both
static and dynamic states. The upper
lip at rest allows for evaluation of the
maxillary incisal position and in a
dynamic or smile state allows for
assessment of the position of gingi-
val tissues. The lower lip phoneti-
cally determines the labiolingual
position of the maxillary incisors and
in a dynamic state provides a guide-
line for the curvature of the incisal
plane.1,2
The “LARS factors,” as des-
cribed by Ahmad,2 provide infor-
mation for determining the appro-
priate display of the maxillary
anterior teeth. These factors are: lip
length (static: short, medium, long);
age (the elderly typically show less of
the maxillary and more of the man-
dibular anterior teeth); race (patients
of African descent frequently display
less of the maxillary anterior teeth
than Caucasian patients); and sex
The International Journal of Periodontics & Restorative Dentistry
(females generally show twice as
much of the maxillary incisors as
males).
The vertical references are the
facial midline, axis of the dental mid-
line, and mediolateral assessments
of tooth position. Ideally, the facial
midline and axis of the dental mid-
line should be parallel and coincide,
but minor deviations are not neces-
sarily distracting.1,2
The sagittal references include
the nasolabial angle (in males 90 to
95 degrees and in females 100 to
105 degrees), which allows assess-
ment of upper lip support derived
from the gingival two thirds of the
maxillary anterior teeth. The Rickett’s
E plane is used to evaluate the pro-
file and maxillomandibular relation-
ships. The Camper’s plane should
parallel the occlusal plane.1,2
The phonetic references include
the “M” sound, used to determine
rest position (with absence of tooth
contact) and assessment of the dis-
play of the maxillary incisors at rest.
The “F” or “V” sounds help deter-
mine the lingual tilt of maxillary
incisal edges, and the “S” position is
used to capture the vertical dimen-
sion of speech with near maxillo-
mandibular incisal edge contact.1,3
Dental composition also in-
cludes the evaluation of the size,
shape, and intra- and interarch rela-
tionships of the teeth. The central
incisors should have a 7.5:8.0 width-
to-length ratio and be dominant to
be most esthetic. The “golden pro-
portion” is an ideal, but it is not
always evident. The axial inclinations
of the anterior teeth should con-
verge medially, and the incisal plane
should be parallel to the commis-
sure plane. The “smile line” should
be convex and follow the curvature
of the lower lip. Unworn incisal
edges and pronounced incisal
embrasures are associated with
youth and femininity, whereas worn
incisal edges and diminished incisal
embrasures are associated with
aging and masculinity.2,4–6
Gingival composition describes
the esthetic makeup of the gingival
tissues that “frame” the teeth.
Gingival levels on central incisors
should be the same, while lateral
incisors can display subtle deviations.
The “gingival aesthetic line” (GAL)
described by Ahmad2 is the line con-
necting the zeniths of the central
incisors and canines and intersects
the dental midline. The GAL can be
esthetic in several patterns as long as
there is a sense of order. Angles can
be 45 to 90 degrees, with the lateral
incisors on or 1 to 2 mm above/
below the GAL. Gingival contours, in
health, tend to follow the form of
the underlying bone. When there is
a scalloped form, there is generally
closer root proximity. When shallow
form is displayed, the roots are usu-
ally divergent or a diastema may be
present. Gingival zeniths of the cen-
tral incisors and canines are distal to
the long axes of these teeth, and the
zeniths for lateral incisors are closer
to the long axis. The interdental
papillae should be intact, and gingi-
val exposure during smiling should
be 3 mm or less to generally be con-
sidered esthetic.1,2
Symmetry and diversity also play
roles in the evaluation of the esthetic
composition. Currently, many

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patients are influenced by the
“media smile,” which has an altered
ideal compared to the more natural
esthetics of teeth. To many, even
incisal edges and white teeth now
equate with youth and success, and
dentistry frequently has to overcome
this stereotypical image to effect a
truly beautiful smile. In design, sym-
metry or very subtle asymmetry
should exist close to the midline,
whereas greater asymmetries are
acceptable away from the midline.
Also, the dental midline may deviate
from the facial midline in many situ-
ations and still be esthetically pleas-
ing.1
The expansion of the current
state of esthetic dentistry should
include identification of the charac-
teristics associated with cases with
more advanced esthetic compro-
mises and determine which clinical
corrections need to be applied in
each situation to create the most
optimum environment, or frame-
work, for esthetic restoration. It is
evident that not all situations lend
themselves to an optimum result, as
noted above. The well-managed
case with advanced problems, where
remarkable improvements in esthetic
appearance are achieved, can be as
elegant as an “optimum” case when
the preoperative condition is con-
sidered. However, these types of
cases are not often presented in
esthetic dentistry forums because
the standards for presentation
appear set to the idealized situation.
This limits the value of presented
cases and techniques because of the
narrowed scope and redundancy
that has become so evident.
87
However, if such esthetic com- 5. It facilitates the projection of the
promises were included in a classifi- limitations of treatment and the
cation, cases could be categorized final result of therapy that is likely
accordingly, and levels of realistic achievable.
expectations could be applied to
assess the effectiveness of therapy. In general, a classification sys-
The literature presents several dif- tem facilitates the recognition of
ferent classification systems that problems, communications between
have bearing on esthetic results and cotherapists, planning of treatment,
ample references to various guide- and expression of achievable results
lines for assessing dental esthetic to the patient. In any aspect of treat-
composition. There are also descrip- ment, this is invaluable.
tions of the conditions that can
detract from optimum appearance;
however, a classification that includes
esthetically compromised case types
has not been presented.7–15 Consid-
ering that there is not currently a
published classification system to
this effect, it is the purpose of this
article to tender such a classification
of altered dental esthetics.
Prior to presenting a classifica-
tion of altered dental esthetics, it
would be helpful to delineate some
of the reasons such a system would
be beneficial to the clinician:
1. It facilitates visualization and
communication of the problems
associated with the case type.
2. It connotes the degree of diffi-
culty of accomplishing the re-
quired correction of the associ-
ated problems.
3. It establishes a basis for project-
ing the time needed to achieve
the necessary treatment objec-
tives.
4. It establishes a framework and
some general guidelines for pro-
jecting fees commensurate with
the level of difficulty of treating
the patient.
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The classifications
Altered dental esthetics are divided
into four classes. In each class, the
condition of the framework of
esthetics represents the basis for the
classification. In a sense, the restora-
tion becomes the object of art on the
canvas, and the condition of the sup-
porting structures becomes the
frame that enhances the presenta-
tion. The influential framework con-
sists of:
1. Integrity of the dental arches,
including missing teeth, general
condition of the teeth, occlusion
problems, occlusal plane alter-
ations, midline discrepancies,
and tooth position alterations
2. Integrity of the osseous support,
including the level of the osseous
crest, ridge deformities, tooth
mobility, periodontal defects,
and clinical crown lengths
3. Integrity of the gingival tissues,
including soft tissue levels,
mucogingival deficiencies, gin-
gival clefts, and gingival asym-
metries
4. Orthognathic alterations
Class I: Intact esthetic
framework
In the Class I type, the esthetic
framework is intact. The skeletal,
osseous, and gingival architecture
and the dental arches require no
alteration. The only esthetic require-
ment is the restoration of the teeth.
Here, the achievement of the treat-
ment objective is limited by the
The International Journal of Periodontics & Restorative Dentistry
clinical abilities of the operator and
the technical quality of the labora-
tory support. The focus is primarily
on the choice of the optimal restora-
tion. Proper soft tissue management
during therapy is essential. Impres-
sion making must be minimally trau-
matic, and the provisional restora-
tions must be of a quality that
enhances tissue health. Proper tooth
preparation is critical to enable the
laboratory technician to achieve a
quality result. Here, excellent labo-
ratory results will enhance clinical
management, but they cannot com-
pensate for poor clinical controls16,17
(Fig 1). Of special note, in Class I
cases as well as the more advanced
situations, a high lip line will always
create a higher degree of treatment
difficulty.
Class II: Minor alteration in
esthetic framework
In the Class II situation, there are
minor alterations evident in the
esthetic framework. The patient may
present with a minor midline dis-
crepancy, minor gingival height dis-
crepancy, a hopeless or missing
tooth but intact osseous and gingi-
val tissues, minor noncomplicated
orthodontic problems, or perhaps a
noncomplicated implant situation.
In each of these situations, the prob-
lems are readily correctable with
appropriate treatment, and the case
is readily convertible to Class I status.
In these circumstances, appropriate
and predictably achievable ortho-
dontic, periodontic, endodontic,
and oral surgical procedures must
precede completion of restorative
endeavors.18–27 Once the esthetic
framework is reestablished, the Class
I restorative objectives would then
be applicable (Fig 2).
Class III: Significant alterations
in esthetic framework
In the Class III situation, the esthetic
framework presents with one or
more advanced alterations. There
may be occlusal plane deviations,
severe midline shifts, or other ortho-
dontic problems that present with
limited prognoses because of insuf-
ficient or poor anchorage, deficiency
of alveolar bone dimension, or pa-
tient noncompliance. Osseous de-
fects requiring potential grafting pro-
cedures may not be as predictable
because they may require vertical
augmentation as opposed to more
predictable horizontal augmentation
procedures. Patients may tire of re-
peated surgeries and refuse addi-
tional procedures before all of the ini-
tial objectives are achieved. Clinically
elongated teeth with loss of inter-
dental papillae may create esthetic
compromises that are not amenable
to total elimination. There may be
significant loss of periodontal tissues
or marked edentulous ridge loss or
deformation, or the patient may have
hopeless or missing teeth with sig-
nificant loss of osseous substructure.
Unlike Class II cases, in these cases
the esthetic framework may not be
converted readily or predictably to
Class I status. Yet, with appropriate
treatment, a reasonably acceptable
appearance should be achievable as

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Fig 1a Patient expressed concern over the incisal wear of the
maxillary central and right lateral incisors. She wished to have
esthetic correction accomplished but was concerned about main-
taining a natural appearance. The esthetic framework was intact,
exemplifying a Class I situation.
Fig 2a This patient disliked the appearance of the existing cer-
amometal fixed partial denture on the maxillary right central incisor
to the left lateral incisor. She objected to the appearance of the
“dark line” around the gingival collar of the right central incisor and
to the open papillary space between the central incisors. She also
expressed a desire for a general overall enhancement of her smile,
emphasizing that she wished to have brighter and more even teeth.
89
Fig 1b Restoration of both maxillary central incisors and the right
lateral incisor was accomplished using porcelain laminate veneers
fabricated to be in harmony with the appearance of the adjacent
teeth. Here, as in other Class I examples, no procedures were
required prior to the restorations.
Fig 2b Original fixed partial denture was made with the left central
incisor as a modified ridge-lap pontic. In the new restoration, this is
contoured as an ovate-type “emergence” pontic. The patient had an
abundant amount of keratinized attached gingiva over the edentu-
lous ridge, suggesting that a gingival graft had previously been per-
formed, although the patient could not recall. In the process of the
gingivoplasty to establish the ovate pontic, the proximity of the labi-
al frenum became apparent. A frenectomy was performed to stabi-
lize the tissues. The patient wished to have the restorations extend-
ed distally into the premolar areas to enhance the esthetic result. All-
ceramic single units were used, with the exception of the fixed
ceramic segment between the right central and left lateral incisors.
Attention was given to the establishment of a more youthful smile
line as well as correction of the patient’s initial concerns. In this Class
II case, the esthetic framework was essentially intact and only minor
soft tissue corrections were required prior to restoration.
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Fig 3a This patient presented with signifi-
cantly more advanced problems. The max-
illary left central and lateral incisors were
hopeless because of advanced bone loss
associated with failure of prior endodontic
procedures and apicoectomies. The loss of
these teeth would result in a very signifi-
cant defect in the patient’s anterior maxilla.
long as the clinician and the patient
understand that some compromise
from the ideal is necessary.27–34 It is
best that this understanding is
reached at the onset of therapy
rather than at the end, when the
patient could be disillusioned be-
cause of unrealistic expectations. In
these cases, recognizing the ap-
propriate class type preoperatively
will be of benefit in realizing poten-
tial limitations and translating these
to the patient (Fig 3).
Class IV: Orthognathic
deformities
An orthognathic problem by itself
constitutes a compromise in the
esthetic framework, even if all other
framework aspects are intact. These
include severe angle Class II or III
deformities, anterior open bite, ver-
tical maxillary excess, marked asym-
metry, and severe occlusal or incisal
The International Journal of Periodontics & Restorative Dentistry
Fig 3b Radiographs demonstrate the
severity of the problem. The fragile inter-
septal bone between the two hopeless
teeth would likely be lost following extrac-
tion, resulting in a depression in the ridge
and loss of the papillae needed for main-
tenance of an esthetic appearance. This
case would be classified as Class III
because of the advanced nature of the
problems and unpredictable nature of
total preprosthetic repair.
plane alterations (Fig 4).35–37 If the
patient presents with solely Class IV
problems, these cases can be con-
verted to Class I with appropriate
orthognathic and orthodontic pro-
cedures. It must be recognized that
some patients will resist orthognathic
surgery; in this case, nontreatment
will mean compromise of the poten-
tial idealized result. On the other
hand, some patients become very
enthusiastic when they learn of pos-
sibilities and options that are avail-
able to them. If Class II problems are
also present, these must be treated
in the same manner as if the orthog-
nathic component were not present
(Fig 4b). Problems can be worsened
if Class III esthetic framework com-
promises are superimposed. In some
cases, the severity of the Class III
problems can be lessened if these
are addressed in conjunction with
the orthognathic treatment. In many
advanced combination cases,
patients sometimes will happily
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accept an improved appearance that

is not ideal, because orthognathic
therapy tends to be dramatic. This is
especially true if the patient appre-
ciates the scope of their problems
and is given an understanding of the
limitations associated with the cor-
rection of the various aspects of their
esthetic condition.
Figs 3c and 3d Following the extractions, ridge reconstruction was accomplished by
Generally, when treating pa- means of guided bone regeneration, followed by a subepithelial connective graft to add
tients with esthetic problems, the facial and ridge height. This was done simultaneously with a contiguous free gingival graft
on the ridge crest that obturated the space in the crestal incision. These procedures
clinician should attempt to reduce reestablished the labiolingual contours as well as the height of the edentulous ridge and
the patient’s circumstances to the created a situation where ovate pontics could be employed. (Periodontal surgery per-
formed by Dr Robert L. Holt, West Palm Beach, Fla.)
lowest achievable class status. Re-
sults are also limited by the patient’s
acceptance of therapy, compliance,
and healing response.

Using the classifications

Patients can be described using a

preoperative class in combination
with achievable or achieved post-
operative classification.
Preoperative classifications
Figs 3e and 3f Ovate pontic form development in conjunction with prosthetic increase in the
incisogingival length of the contact areas enabled the partial reestablishment of the interdental
papillae. The creation of greater dominance of the central incisors draws the eye away from the
tissues and presents an overall very acceptable and pleasing esthetic appearance for this
attractive 36-year-old woman. Her lip line also provides ample coverage for her gingival tis-
sues. The postoperative radiographs demonstrate the reconstruction of the osseous deformity.

If the patient’s condition can be

effectively described by one classi-
fication, then it would be simply
stated as Class I, II, III, or IV. If a
patient has combined characteris-
tics, the condition would be
described using a virgule (/) to sep-
arate the classes (eg, Class II/III).
This might be used to describe a
patient with generalized Class II
characteristics but some localized
Class III areas. If the patient has an
underlying orthognathic condition,
however, this characteristic would
be expressed first, followed by the
classification of the overlying
esthetic framework problems (eg,
Class IV/III or Class IV/II).
Postoperative classifications
A Class II patient who completes
treatment with successful conversion
to Class I status would be referred to
as Class II-I, using a hyphen (-) to
symbolize the change. The same
would apply to other classes that are
returned to Class I status (eg, Class
III-I or Class IV-I). If the patient has
combined characteristics (eg, Class
IV/III or Class IV/II) and is successfully
treated, the case could be described
as Class IV/III-I or -II, indicating
restoration to a Class I or II status. If

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the patient were restored without

reduction of class because of lim-
ited results or nonacceptance or
compliance with treatment, the
description would express only one
class (eg, Class II-II).
If the patient is restored to an
acceptable esthetic appearance in
Figs 4a and 4b This 17-year-old female suffered development of a severe anterior defect
spite of residual underlying frame-
caused by a large resorptive lesion on the maxillary left central incisor root. The lesion was work deficiencies and prosthetic
the sequela of a long and poorly controlled orthodontic program designed to treat the con- methods were used to conceal these
genital absence of the lateral incisors by bringing the teeth posterior to the spaces forward
to contact the distal surfaces of the central incisors. Her esthetic condition was further com- residual problems, then the case
promised by the ectopic eruption of the right first premolar anterior to the right canine and could be described as having a “cos-
altered passive eruption on the right side.
metic” result. These measures would
include techniques such as use of
tissue-colored porcelains to simu-
late missing papillae or conceal
excessive crown length.34 Remov-
able gingival masks would also be
included in this description. The
term cosmetic would be used to
describe concealment, as opposed
to “esthetic correction,” which
would imply elimination of the prob-
lem through therapeutic measures.
Figs 4c and 4d Following extraction of the hopeless central incisors and initial healing, the Thus, when “(cosmetic)” is used at
patient refused to undergo any procedures recommended to reconstruct the edentulous
ridge. This eliminated the ability to reduce the excessive clinical crown length or place estheti- the end of a description, it would
cally positioned implants. The patient agreed only to have periodontal surgery to achieve indicate that all or some of the un-
pocket elimination and correct the altered passive eruption. This did help to improve the levels
of the gingival tissues. The apical positioning also helped to narrow the root dimensions of the
derlying problems are still present,
right first premolar and left canine, which were in the lateral incisor positions. This facilitated but they are concealed through
the contouring of these restorations as lateral incisors. The left first premolar was also shaped prosthetic techniques rather than
to resemble a canine. The patient was restored with a fixed ceramometal restoration using gin-
giva-colored ceramics to simulate the replacement of lost soft tissues and reduce the appear- having been successfully corrected
ance of excessive clinical crown length. In this situation, the patient’s Class III framework status through therapy. Therefore, the clas-
was not reduced and a prosthetic method was used to achieve a Class III-III (cosmetic) result.
sification would be stated as Class III-
III (cosmetic) if there were no cor-
rective measures achieved (Fig 5). If
partial esthetic framework correction
were accomplished prior to the ap-
plication of the prosthetic measures,
then the situation could be des-
cribed as Class III-II (cosmetic).

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Fig 5a This patient's Class IV “gummy smile” results from vertical
maxillary excess that can only be corrected by surgical means.
Here, she is depicted undergoing orthodontics in preparation for
orthognathic surgery.
Fig 5b Following the orthognathic surgery, the patient still has a
minor problem with the level of the gingival tissues on the maxil-
lary right lateral incisor. Her appropriate esthetic classification
would therefore be Class IV-II prior to any additional treatment and
Class IV-I if the altered gingival height were corrected.
(Photographs courtesy of Dr Stephen Rimer, Boca Raton, Fla.)

Conclusion Acknowledgment 4. Burger S. The arrangement of anterior

The use of a classification of altered
dental esthetics would facilitate the
diagnosis, treatment planning, com-
munication of case characteristics
between cotherapists, planning of
treatment time requirements and
fees, establishment of achievable
objectives, and communication with
the patient. Generally, it would aid in
the overall management of esthetic
dental care. It would also enhance
the reporting of cases in the dental
literature and presentations by offer-
ing a frame of reference for assess-
ment of results of therapy. This
would clearly reflect underlying pre-
operative conditions, in contrast to
the idealized situation.
I would like to express my sincere gratitude
to Dr Robert Holt for his editorial assistance
in the preparation of this article.
References
1. Chiche G, Pinault A. Esthetics of Anterior
Fixed Prosthodontics. Chicago:
Quintessence, 1994:13–73, 180–181.
2. Ahmad I. Geometric considerations in
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ciples. Pract Periodontics Aesthet Dent
1998;10:813–822.
3. Spear F. The maxillary central incisal edge:
A key to esthetic and functional treatment
planning. Compend Contin Educ Dent
1999;20:512–516.
10. Morley J. Smile design terminology. Dent
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tion. In: Schärer P, Rinn LA, Kopp FR (eds).
Esthetic Guidelines for Restorative
Dentistry. Chicago: Quintessence,
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5. Touati B. Defining form and position.
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6. Preston JD. The golden proportion revis-
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7. Blitz N. Criteria for success in creating
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38–42.
8. Feigenbaum NL. Aspects of aesthetic
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254.
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