The kinetics of anterior tooth display

Robert G. Vig, D.D.S.,* and Gerald C. Brundo, D.D.S.** University of California, School of Dentistry, Los Angeles, Calif.

entists can usually identify denture wearers at a glance. An untrained observer can identify most dentures by their monotonous tooth positions, contours, and shades. This study deals with one aspect of the "denture look'"--the amount of maxillary and mandibular tooth exposure with the lips at rest. A survey was made of people of all ages with natural dentitions to determine the relationship of lips and teeth and to note the changes that occur with aging in anterior tooth exposure. M a n y prosthodontic techniques require that the maxillary occlusion rim be contoured and adjusted to determine the proposed length of the maxillary incisors. Various textbooks offer guides to establishing a lip length-incisal edge relationship. T h e y do not suggest that this relationship is related to the age of tile patient. T h e other esthetic factor, which has been largely ignored, is the amount of exposure of the mandibular anterior teeth. Boucher and associates ~- suggest modifying the maxillary rim "so that it is gently caressed by the lower lip during pronunciation of the l e t t e r f a n d at a height that allows for the length of the natural tooth plus the amount of bone reduction that has occurred." Heartwell and Rahn ~ suggest that the "maxillary occlusion rim extends approximately 2 millimeters below the relaxed lip." This length is modified until the inferior border contacts the vermillion border of the lower lip w h e n f s o u n d s are made. In some cases a line drawn between the commissures of the lips is used. Sharry 4 says that "for a patient with an average length of upper lip, 1 to 2 millimeters of occlusion rim should be seen when the lip is at rest. For that patient with a short upper lip, perhaps 5 to 6 millimeters of occlusion rim should be seen." Ellinger and associates ~ suggest that with a
D "Read before the Pacific Coast Society of Prosthodontists, San Francisco, Calif. *Clinical Professor of Dentistry. **Assistant Professor of Dentistry.

normal lip the occlusion rim extend just below the resting lip with variations for short or long lips. The textbook instructions make no distinction between the sexes, different ages, or racial types. T h e phonetic aids o f f and v sounds should automatically determine the correct placement of maxillary incisal edges and preclude any other considerations. However, the phonetic system is often not used or results are misinterpreted. This survey was made in an effort to correlate these factors and others with the amount of tooth display with the lips at rest. It was hoped that the information developed by an extensive survey of natural dentitions would furnish guides to denture tooth placement under various conditions. SURVEY T E C H N I Q U E The subjects were examined by the authors in the UCLA clinical spaces. No attempt was made to maintain a racial balance or a fixed male-to-female ratio. Some age groups were larger than others, but all were believed to be adequately sized. No subjects were included with atypical conditions such as traumatized lips, mobile or extruded anterior teeth, extreme abrasion, or prosthetic anterior tooth replacements. Uncooperative individuals were also excluded from tile survey. Data collected included tile subject's sex, race, age, lip type, upper lip length, and the amount of tooth display with tile lip gently parted. This data was analyzed in v~irious ways and charts prepared (Figs. 1 and 2). RESULTS Variability of sexes. T h e average amount of maxillary incisor exposure in men was 1.91 mm. In women almost twice as much maxillary tooth exposure was noted, 3.40 mm. As could be anticipated, the men displayed more of the mandibular incisors than the women, namely 1.23 m m compared to 0.49 m m (Table I).

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ANTERIOR TOO'Ilt DISPLAY

Table I. Tooth exposure by sex

Mean amount of tooth exposed (mml Sex
I

Maxillary central incisor 1.91 3.40

Mandibular central incisor 1.23 0.49

Male Female

Table II. Tooth exposure by race

Mean amount of tooth exposed (mm) Race Caucasian Black Asian Maxillary cenlral Incisor 2.43 1.57 1.86 Mandibular central incisor 0.98 1.42 1.Sb

L..

Fig. 1. The measurement of the amount of exposure of the maxillary central incisors.

There was a large variation within the groups. It is helpful to know that women, on the average, display twice as much maxillary anterior tooth surface as men. Variability of races. The races broadly classified as Caucasian, black, and Asian. In this category nothing of particular significance was found. In the black and Asian individuals the amount of maxillary and man.dibular incisor exposure was roughly equal. The Caucasians exhibited an average of tile male/ female statistics in both maxillary and mandibular exposure (Table II). Vm-iabillty of lip lengths. People with short upper lips display more maxillary tooth structure than l:~.ople wlfh long upper lips. This seems axiomatic, but surprlsingly some dentists still set the anterior teeth t o display 1 to 2 mm of the maxillary incisors regardless of lip length, since this is an accepted rule. The survey findings were explicit and had small ' variations. Als0 note that the longer the upper lip, the more the mandibular teeth are exposed (Table III). The measurement was made from the base of the column to the tip of the phihrum (Fig. 3). Variability of lip types. The lip types were categorized as normal, long, short, heavy, or protrusive. The long and short lip types were covered by the lip length data. The heavy lip is in essence a long lip. The protrusive type has more exposure of both maxillary and mandibular teeth, as was expected. Variabilit)' of age. Groupings were made as follows: under age 29, 30 to 39, 40 to 49, 50 to 59, and 6 0 a n d older. The anticipated pattern was that of a gradual decrease in exposure of the maxillary central

Fig. 2. The measurement of the amount of exposure of the mandibular central incisors.

~,,

---~

Fig. 3. The measurement of the length of the upper lip. incisor with age. No particular thought had been given to exposure of the mandibular central incisor. The most noteworthy information gained from this survey can be seen in Table IV. While maxillary anterior tooth display showed a steady decrease with aging, the mandibular anterior

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Table III. Tooth exposure by length of upper lip

Mean amount of tooth exposed (mm) Upper lip length (ram) 10-15 16-20 21-25 26-30 31-35 Maxillary central incisor 3.92 3.44 2.18 0.93 0.25 Mandibular central incisor 0.69 0.77 0.98 1.95 2.25

in prosthodontic literature would therefore be misleading in making the average Complete denture. In fact, the survey findings demonstrate that the mandibular incisor display in the patients over 60 years of age should be approximately equal to the maxilla O, incisor display in patients under 30 years of age. Treating a l l p a t i e n t s in the same manner regardless of age differences contributes greatly to the "denture look." SUMMARY A N D C O N C L U S I O N

Table IV. Tooth exposure by age

Mean amount of tooth exposed (mm) Age group (yr) U p to 29 30-39 40-49 50-59 60+ Maxillary central incisor 3.37 1.58 0.95 0.46 --0.04 Mandibular central Incisor 0.51 0.80 1.96 2.44 2.95

teeth showed a corresponding increase. The principal exceptions to this pattern were patients with moderate to severe Class II malocclusions. DISCUSSION Regardless of judgment and technical ability dentists can place artificial teeth more correctly if clues are available as to former natural tooth positions. This survey makes available average measurements for patients based on sex, race, lip length, and age. Properly used, it may help furnish a startb2g pohzt for positioning anterior teeth. Mandibular incisor teeth have been largely neglected in considering esthetic denture compositions. This survey shows that the average maxillary tooth display in the group of patients over 60 years of age was --0.04 mm; tooth display was 2.95 mm in the mandibular central incisors. The accepted guidelines

A survey has been presented that correlates measurements of upper lip type, sex, race, and age of dentulous patients with the amount of exposure of tile maxillary and mandibular anterior teeth with the lips gently parted and in tile resting position. Perhaps the most interesting finding was the gradual reduction in the amount'0f maxillary central incisor exposure with an increase in age, accompanied by a gradual increase in the mandibular tooth exposure. The importance of the .smount of mandibular teeth seen in complete dentures has not been sufficiently emphasiied in previous literature. REFERENCES
1. Vig, R. G.: The denture look. j PROSTHVT DE,','r 11:9, 1961. 2. Boucher, C. O., Hickey, j . C., and Zarb, G. A.: Prosthodontic Treatment for Edentulous Patients, ed 7. St. Louis, 1975, The C. V. Mosby Company, p 224. 3. Heartwell, C. M., and Rahn, A. O.: Syllabus of Complete Dentures, ed 3. Philadelphia, 1974, Lea & Febiger Publishers, p 224. 4. Sharry, J. J.: Complete Denture Prosthodontics, ed 3. New York, 1974, McGraw-Hill Book Company, Inc., p 234. 5. Ellinger, C. Vr Rayson, J- H~, Terry, J. M., and Rahn, A. O.: Synopsis of Complete Dentures. Philadelphia, 1975, Lea & Febiger Publishers, p 163.
Reprint requests to: DR. ROBERT G. Via UNIVERSrrY OF CALIFORNIA SCHOOL OF DENTISTRY LOS t'kNGELE$,CALIF. 90024

I N F O R M A T I O N FOR A U T H O R S Most of the provisions of'the Copyright Act of 1976 became effective on january 1, 1978. Therefore, all manuscripts must be accompanied by the following statement, signed by each author: "Theundersigned author(s) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in tile event the work is published. The author(s) warrants that the article is original, is not under consideration by anot!ler journal, and has not been previously published." Authors will be consulted, when possible, regarding republication of their material.

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