Original article

Clinical studies on the appearance of natural anterior teeth in

young and old adults

Rüdiger Hartmann1 and Frauke Müller1,2

1
Department of Prosthetic Dentistry, University of Mainz, Mainz, Germany; 2Department of Gerodontology and Removable Prosthodontics,
University of Geneva, Geneva, Switzerland

Gerodontology 2004; 21; 10–16

Clinical studies on the appearance of natural anterior teeth in young and old adults
Objectives: To evaluate the typical appearance of natural anterior teeth in young and elderly people and
to develop guidelines for the natural appearance of dentures.
Design: Clinical examination and photography. Inclusion criteria were a dental state with natural anterior
teeth and no more than two crowns.
Subjects: A study group (SG) consisting of 64 patients ranging in age from 60 to 86 years (67.3 ± 5.8) and
a control group (CG) composed of 64 dental students aged 21–33 years (25.8 ± 2.4).
Setting: Dental schools of the Johannes-Gutenberg-University Mainz and the University of Leipzig.
Results: Most participants were content with the appearance of their own natural teeth. With relaxed lips
a mean of 1.5 (±0.19) mm of upper incisors and 1.6 (±0.19) mm of lower incisors were visible in the SG
compared with 2.5 (±0.16) and 0.4 (±0.07) mm in the CG, respectively. The subjects in the SG showed a
greater diversity in position of teeth in the anterior arch and this was more often with incisors than with
canines. Features such as stains, cracks and defects were much more noticeable in the SG. An inter-dental
‘black triangle’ seemed to be a typical feature of an aged dental appearance.
Conclusion: The majority of people older than 60 years who still have their own natural anterior teeth
would not wish for a change in appearance if they needed a prosthodontic reconstruction. Thus techniques
for customisation should be promoted to obtain a natural appearance in dentures.

Keywords: natural dental appearance, ageing, toothwear, prosthetic privacy.

Accepted 16 December 2003

social partners may help people to cope. Dentures

Introduction
Life expectancy in industrialised nations is
increasing and prophylactic measures have shifted
tooth loss to later in life. Tooth loss often affects
people in the age-strata who experience major
changes in their life, e.g. retirement, which might
cause an emotionally frail state1. Tooth loss is often
associated with the prospect of ageing and loss of
vitality and might thus induce social withdrawal.
Fiske et al.2 describe the trauma of tooth loss as
being related to a reduced self-esteem, discontent-
ment with their own appearance and the inability
to openly discuss this with friends and relatives.
They further found a fear of the inability to hide
the removable denture from others. In this difficult
situation, a denture that not only functions well
but also disguises the removable denture from
made for elderly patients often look artificial
because they use prefabricated juvenile moulds and
are set up in a standardised manner. In contrast the
natural dentition is subject to a physiological aging
process, which changes its morphology and
appearance. For the production of a denture that
cannot be recognised as ‘false teeth’, the challenge
lies in a dental appearance that matches the
patient’s character but also looks age-related.
Off-the-shelf denture teeth are largely deficient in
age-related appearance as most are designed to
produce an immaculate juvenile appearance. Con-
sequently they can only be considered ‘raw mate-
rial’ if a natural appearance is desired. LaVere3
compared the moulds from six different manufac-
turers with the teeth of dental students and found
them to be predominantly smaller than the natural

10
2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16

 Clinical studies on the appearance of natural anterior teeth
teeth. For a maximum possible individuality it was
even recommended to integrate a patient’s own
extracted teeth into a denture4. In the dental lit-
erature there are numerous references to selecting
artificial teeth, e.g. with reference to the facial
shape5, phenotype6, size and shape of the nose7,
gender or even personality8,9. Also old photographs
were recommended for orientation10,11. Manufac-
turing a denture with respect to a patient’s age is
discussed less frequently. Vig and Brundo12 com-
mented on the visibility of incisors which shifts in
favour of the lower ones with age. Frush et al.13 state
that the effects of mesial shift, loss of individual teeth
or a long-lasting malocclusion could be incorporated
into a set-up to create an aged appearance. Besford
and Müller14 recommend stains, crack or even fill-
ings for an age adequate appearance.
The aim of this study was to evaluate the typical
appearance of natural anterior teeth in young and
elderly adults, with emphasis on features such as
colour, position, wear, stains and cracks as well as the
appearance of the surrounding soft tissue. In addi-
tion, the subjects were asked about their preferences
regarding the design of a hypothetically necessary
denture. Based on these findings, a further aim of the
study was to develop guidelines to create a natural
appearance of dentures made for elderly people.
Material and methods
The study group (SG) was composed of a total of 64
patients (28 women and 36 men) from the Dental
Schools of the Universities Mainz or Leipzig. Their
age ranged from 60 to 86 years (67.3 ± 5.8). The
control group (CG) consisted of 32 female and 32
male dental students aged between 21 and 33 years
(25.8 ± 2.4). Inclusion criteria for the participation
in the study were a dental state with natural
anterior teeth and no more than two crowns.
During a clinical examination the general phy-
sique and the facial shape of the subjects were
assessed. From the Vitapan anteriores form chart a
mould was chosen, that resembled the subjects’
teeth most. The colour of each individual incisor
and canine was judged using a shade guide (Vitapan
3D Master; Vita Zahnfabrik, Bad Säckingen,
Germany). The visibility of the anterior teeth was
measured whilst the subjects were asked to slightly
open their relaxed lips without smiling. Further the
patients’ oral hygiene was clinically assessed.
Photographs were taken en face with and without
lip-retractors using a Dental Eye III (Yashica,
Kyocera GmbH, Hamburg, Germany). In addition
the dental arches were photographed from above
through a mirror.

2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16
11
Subsequently the subjects (SG, n ¼ 61; CG,
n ¼ 64) were asked, if they were satisfied with the
appearance of their anterior teeth or if they wished
an alteration in the hypothetical case that a pros-
thetic restoration was necessary. Those participants
who were content with their appearance were
asked to specify if they would only wish to keep the
shape and position of their teeth or if they also
wanted individual features such as stains and fill-
ings. Those who wished for a change in dental
appearance were asked if they wanted only a
lighter shade or an ideally formed immaculate
dental arch.
Analysis of the photographs was performed with
regard to fillings, stains, cracks and defects. The
transparency of the incisal edge and visibility of
the dentine core were assessed. The shape and the
symmetry of the dental arch, gaps, a crowded tooth
position or central incisors positioned in a butterfly
position were noted. In addition, the axis inclina-
tion of single teeth in mesial-distal and oro-ves-
tibular direction was recorded. The surrounding
soft tissues were judged for colour, shape of the
papillae and interdental black triangles as well as
the shape of the gingival margin including possible
recession.
All clinical examinations and photo analyses
were performed by one single operator (RH). Dif-
ferences between SG and CG were statistically
verified using the Fisher’s exact test.
Results
No correlation could be established between a
certain tooth mould and the subject’s physique or
shape of the face. In the SG all VitaPan anteriores
teeth would have had to be customised to match
the shape of the natural teeth; in the CG a match to
the customised moulds proved easier. The VitaPan
3D master shade 3 or 4 was found predominantly
in the SG, whereas the CG presented most fre-
quently with shade 2 (Fig. 1).
The visibility of the upper incisors by 2 mm
with the lips relaxed was found in only 19 sub-
jects of the SG, but in 30 of the CG. Eighteen
subjects in the SG showed more of their upper
anterior teeth and 32 in the CG. However, 24
subjects in the SG did not expose their upper
anterior teeth at all; in the CG this was the case
for only two subjects (p < 0.0001). In contrast, the
lower incisors were visible in 43 subjects in the SG
and 19 in the CG (p < 0.0001). The results indi-
cate clearly, that in older subjects, the lower
anterior teeth were more visible than the upper
ones (Fig. 2a,b).
12 R. Hartmann, F. Müller

40
SG upper canines
35 SG upper incisors
SG lower canines
SG lower incisors
30 CG upper canines
Study
study group
group CG upper incisors

25 control
Control group
group
CG lower canines
CG lower incisors
(n )

20
15
10
5
Figure 1 The colour values from the
0
Vitapan 3D shade guide which
1 2 3 4 5 showed the closest match to the
VitaPan 3D master ® shade natural teeth.

Figure 3 Tooth arrangement of upper and lower ante-

rior teeth in the study group (SG) and control group (CG).

jaw were matched only in 25 subjects of the SG

Figure 2 Clinical examples of the visibility of teeth with
the lips relaxed in (a) 30-year-old female subject and (b)
72-year-old male subject.
When assessing the shape of the dental arches in
the anterior maxilla viewed from above they
seemed mostly flattened in the SG (n ¼ 35), but
distinctly more rounded in the CG (n ¼ 43)
(p < 0.05). In the present study it became evident
that more subjects in the SG (n ¼ 36) than in the
CG (n ¼ 10) showed an asymmetry in the anterior
arch (p < 0.0001). The midlines of upper and lower
and 32 subjects of the CG. The subjects in the SG
showed a greater diversity in tooth position than
those in the CG. For example only three subjects in
the CG had gaps in the upper front, in the SG there
were 10. Predominantly in the lower (SG, n ¼ 37;
CG, n ¼ 21; p < 0.001) but also in the upper
anterior segment more subjects in the SG (n ¼ 19)
than the CG (n ¼ 10) presented with a crowded
tooth formation (Fig. 3). Twisted or inclined indi-
vidual teeth were observed prevalently in the SG,
not only in mesio-distal but also in oro-vestibular
direction (p < 0.0001). Inclined or rotated tooth
positions were more often observed in incisors
than in canines. Inclinations were found rather in
mesial than in distal direction, only the lower
anterior teeth were tilted more often distally
(Fig. 4).
Abrasions were more distinct in the SG
(p < 0.0001). The lower canines showed the most
progressive abrasions both in the SG and the CG.
The lower canine proved the most abraded tooth

2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16

 Clinical studies on the appearance of natural anterior teeth 13

Tooth inclination: Mesial Distal None Mixed Crowned Features: Cracks Stains Defects
60 60
Control group Study group
Study group
50
Incisors 50

Canines
Incisors
Canines
40
40
Canines Control group

(n)
30
(n)

30
Incisors Incisors
20
20
Canines
10

10
0
Upper Lower Upper Lower jaw Upper Lower Upper Lower jaw
0
Upper Lower Upper Lower jaw Upper Lower Upper Lower jaw
Figure 6 Features such as cracks, stains and defects on
Figure 4 Mesial-distal inclination of individual teeth in incisors and canines of the study group and control
the study group and control group. group.

Dentine core: Not visible Slightly visible Strongly visible Crowned

60
Control group
Canines Incisors
50
Study group
40
Incisors
(n)

30
Canines
20

10

0
Upper Lower Upper Lower jaw Upper Lower Upper Lower jaw

Figure 5 Degree of abrasion indicated by visibility of

dentine core in the study group and control group.

in the anterior arch (Fig. 5). Abrasion was also

present in both, the SG and the CG in the
interdental contact areas, which presented pre-
dominantly broad (SG, n ¼ 47; CG, n ¼ 42),
rather than pointed in shape. Incisal transpar-
ency seemed most prevalent in the incisors of the
CG and most rarely found in the canines of the
SG.
The teeth in the SG showed a greater preva-
lence of features like cracks, stains and defects
than those in the CG (p < 0.0001). In the SG
cracks in the enamel were found most often in Figure 7 Clinical examples of features such as cracks,
upper (n ¼ 49) and the lower incisors (n ¼ 52). stains and defects in (a) a 29-year-old woman with almost
The canines showed the least cracks in both ‘flawless’ teeth and (b) a 78-year-old female subject.
groups. Stains were found more frequently in the
upper than the lower jaw in both groups. Stains Gingival recessions were found more frequently in
were also the one feature found most commonly the SG (n ¼ 45 upper jaw, n ¼ 42 lower jaw) than
in the CG. In both groups, defects were found the CG (n ¼ 6 upper and lower jaw). Interdental
most frequently in the upper incisors (Figs 6 and ‘black triangles’ because of eroded papillae were
7a,b). distinctively more common in the SG (n ¼ 43 upper
The majority of the subjects in the SG (n ¼ 48) jaw, n ¼ 32 lower jaw) than in the CG (n ¼ 7 upper
and all subjects in the CG had a good dental hygiene. jaw, n ¼ 3 lower jaw) (p < 0.0001).

2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16

14 R. Hartmann, F. Müller

Study participants

CG n = 64
SG n = 61

Content with appearance Wish for an alteration with

of own, natural teeth a hypothetically necessary
prosthodontic reconstruction

CG n = 38 CG n = 22
SG n = 35 SG n = 18

Would also wish to retain Would like to only copy Would like to copy Would wish for an Figure 8 Decision tree concerning
features such as stains shade, shape shape and immaculate
and fillings and position position of teeth ideal dental the demand for a natural appearance
appearance
with a lighter shade in the hypothetical case of a
CG n = 1 CG n = 38 CG n = 3 CG n = 22 prosthodontic reconstruction being
SG n = 3 SG n = 35 SG n = 5 SG n = 18
necessary.

When asked about their preference regarding area, where most teeth in the SG, as in the CG
the appearance in the hypothetical case that they presented with plane contact areas probably
needed a prosthodontic reconstruction, 43 subjects caused by abrasion and the physiological mesial-
in the SG and 42 subjects in the CG stated that shift of the permanent dentition. Consequently all
they were content with the appearance of their Vitapan anteriores tooth moulds would have to
own teeth and wished for this appearance to be be modified to match the natural appearance of
copied. Of these, three subjects in the SG and one the aged teeth. None of the four basic forms of the
in the CG also wished to have distinct features Vitapan anteriores mould chart was found to be
such as fillings and stains copied. Five subjects in predominant and it was striking that the teeth of the
the SG and three in the CG wished for a copy of subjects in the CG were easier to match to the mould
their own teeth, but would want them to be a charts than those in the SG. The denture teeth are
lighter shade. An ideally formed immaculate row therefore to be regarded as basic forms and are not
of teeth in a possible denture was desired by 18 typical for naturally aged teeth. They should be
subjects in the study group and 22 in the control customised by grinding, which has also been stated
group, which represents about one third of each by Frush et al.13 As artificial teeth are mostly used for
group (Fig. 8). prostheses for elderly people, it would therefore be
desirable to add to the range of commercially
available denture teeth a ‘line’ that implies the
Discussion
features of the aged tooth in a manner, that creates a
The present data were collected in a cross-sectional natural dental appearance and thus allows the
study design; thus the described differences between patient to maintain his ‘prosthetic privacy’14,
groups might not necessarily be attributed to the namely not to advertize the removable denture to
ageing process. Most parameters were assessed any onlooker, if he/she wishes to do so.
subjectively, but only one operator performed the The darkening of the dentine core as described
clinical examinations and the photo analyses. by Meyer15 and a flattening of the surface struc-
Generations of dental students were taught that ture from abrasion resulting in a different light
the mould of the teeth correlates to the shape of the reflection lead to an altered colour impression for
face5 and the constitutional shape of the patient6. aged teeth. The average tooth shade found in the
Although the latter method seems clinically more SG was 3.4 (±0.84) and 2.5 (±0.65) in the CG with
or less valid, the present study could not confirm the Vitapan 3D master shade guide. Dentures for
such a correlation. However, a larger number of aged people should therefore be manufactured
subjects than used in the present investigation using teeth with a shade of 3 or 4, if the patient opts
might be necessary to statistically validate these for an age-related appearance. The widespread
‘rules’ because the constitutional type is often assumption that the canines have a slightly darker
diluted by weight and age. shade than the incisors seems more relevant in the
The results confirm that features like abrasion younger population. It should however be consi-
and the loss of incisal transparency occur more dered, that in the present study five patients in the
often in aged subjects than in younger individuals SG wanted brighter, and 18 patients more ‘ideal’,
which was previously described by Meyer15 and teeth than their natural ones, a wish that should be
Morley16. Wear was also present in the interdental respected, especially in those patients who are

2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16

 Clinical studies on the appearance of natural anterior teeth
institutionalised where prosthetic privacy is often
of minor importance.
Features such as stains, cracks and defects were
found mostly in the SG, predominantly on incisors,
more than likely due to the fact that canines are
less exposed and have a greater volume and a
thicker layer of enamel.
The results indicate that the dental arches in
the elderly population were more frequently
asymmetrical and flattened, to which an unre-
stored loss of posterior teeth and/or the physio-
logical mesial-shift might have contributed.
Further, the midline was found unmatched
between upper and lower arches in most subjects
investigated. A crowded tooth position was found
significantly more often in the SG. Gaps and
diastema might have occurred from periodontal
problems and/or a loss of posterior occlusal sup-
port. A lack of orthodontic treatment in the SG
might further explain the differences between SG
and CG, but the low revalence of symmetry is still
typical for the generation of patients who now-
adays need removable dentures. Thus contem-
porary guidelines for a natural appearance of a
denture should include the introduction of a
certain asymmetry.
Another tradition in dental teaching states that
the anterior teeth should be exposed 1–2 mm
with the lips relaxed. This rule however, could
only be confirmed for about one-third of the
subjects of the SG, and half of the subjects in
the CG. By contrast, in the present study 43 of the
older subjects showed some of the lower anterior
teeth. The reason for this might be that the upper
lips get longer as the facial tissue and muscles
change with age17–19.
The evaluation of the inclination of single teeth
showed, that in the SG as well as in the CG, canines
were either tilted mesially or positioned vertically.
Interestingly incisors were tilted more often in
various directions in the SG than in the CG. The
greatest variability was found in the lower anterior
region. Lower anterior teeth seem to be the first
teeth to shift position, probably because of their
small anchorage.
The good oral hygiene of most subjects accounted
for a pale and healthy colour of the gingival mar-
gins. Therefore a stained denture resin should
preferably be of a lighter shade. Significantly more
patients in the SG than in the CG presented with
interdental ‘black triangles’ caused by recession of
the papilla. Recession as a sign of age is also des-
cribed by Iacopino and Wathen20. Given the
patient’s willingness and ability to clean those spa-
ces adequately, they may be incorporated into a

2004 The Gerodontology Association, Gerodontology 2004; 21: 10–16
15
denture design and contribute to an age-related
dental appearance.
The predominant wish in the SG for a customised
denture with a natural appearance could be related
to the subjects’ ‘young’ age; only few subjects were
older than 70 years. People in this age group
mostly lead an active life and are socially involved.
Often they associate tooth loss and a removable
denture with ageing and mortality. Consequently
removable dentures are often concealed carefully
from any onlooker. Once dependent and institu-
tionalised, patients seem less concerned about their
prosthetic privacy. It is however important to bear
in mind that the SG had not yet experienced the
loss of anterior teeth. The demand for a natural
appearance might be rather different once this
experience was felt and the restoration of the
anterior teeth was no longer a hypothetical but a
real issue.
Summary and conclusions
The results suggest, that many elderly subjects
with natural teeth would desire a hypothetical
denture to imitate their present appearance,
rather than an immaculate row of teeth, which
would uncover them as denture wearers to an
onlooker.
The following guidelines for a natural and age-
related appearance of a denture could be concluded
from the present investigation:
If ever possible the shape and position of the
denture teeth should be copied from the natural
teeth of the patient. Lacking documents like casts
or the extracted teeth, an old photograph of the
patient is often the last documentation of the nat-
ural dentition.
Furthermore the following features seem typical
for an aged appearance:
• Upper and lower anterior teeth are often equally
visible with relaxed lips
• The lower midline may divert from the upper one
• The anterior arch may be flattened and asym-
metrical
• The lower incisors are often positioned in a
crowded formation
• Inclinations or rotations of individual teeth
appear more frequently in incisors than canines
• Diastema or single gaps may occur
• The tooth shade is mostly Vitapan 3D Master 3
or 4
• Most incisal edges show abrasion; in lower
canines often with exposure of the dentine core
• Cracks, stains and defects are more prevalently
found in incisors rather than in canines
16 R. Hartmann, F. Müller
• The interdental contact zones are plane
• ‘Black triangles’ result from the recession of the
interdental papilla
All or some of these features can be incorporated
into an artificial denture to achieve a natural and
age-related appearance which supports the patient
in keeping his prosthetic privacy and leading a
confident social life. Thus techniques of customi-
sation should be promoted to obtain a natural
appearance in dentures.
Acknowledgements
Thanks are due to Dr Martin Schimmel from the
Prosthetics Department of the Dental School of the
Universität Leipzig for his support in recruiting
subjects.
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Correspondence to:
Professor Frauke Müller,
University of Geneva, Department of
Gerodontology and Removable Prosthodontics,
19 rue Barthélemy-Menn,
CH 1205 Geneva, Switzerland.
E-mail: frauke.mueller@medecine.unige.ch