C O N T I N U I N G E D U C A T I O N 2 5

GEOMETRIC CONSIDER ATIONS IN

A NTERIOR DENTAL A ESTHETICS:
RESTORATIVE PRINCIPLES
Irfan Ahmad, BDS*

AHMAD
10
While aesthetics is traditionally regarded as an artistic point of origin from which modifications can be devel- 7
concept, quantifiable scientific principles are used in its oped. In dental aesthetics this starting point is the law of

SEPTEMBER
development. Dental aesthetics are governed by mathe- nature. The clinician should commence with a knowledge
matical parameters that, when applied by the clinician of the geometry that nature uses to determine anterior
and laboratory technician, can achieve restorations with dental aesthetics. The four elements that contribute to ante-
a unique aesthetic appearance. These geometric laws rior aesthetics are the facial, dentofacial, dental, and gin-
should not be viewed as immutable, but as useful guide- gival compositions. This article presents a discussion of
lines for the fabrication sequence. This article demon- these principles as they relate to the achievement of aes-
strates a series of geometric principles for the anterior thetic maxillary anterior restorations.
maxillary dentition that can be utilized in the develop-
ment of aesthetic restorations. Facial Composition
The facial composition is the most important element to the

T he self-perception of every patient is inherently

unique. This perception is dictated by a variety of
environmental, psychological, and hereditary factors. It
patient. It is this composition that influences most patients’
concept of an aesthetic smile. The reason for this is that
most media images of beauty are concentrated around
is important for the clinician to respect this image; contra- the face, and society is rarely exposed to a smile at the
diction of the image would be iconoclastic and risks alien- close distance routinely observed in a clinical setting.
ation of the patient, perhaps to the extent that treatment
may be sought elsewhere. While preserving clinical judg-
ment, the clinician must also accommodate the requests Facial Midline
of the patient, which are constantly modified by one’s
id, peers, and media pressure. Within these intrinsic and
extrinsic influences, the laws of nature maintain a status
quo. Mathematical language has always been con-
sidered the only reference by which nature can be com-
prehended.1 Consequently, it is necessary to establish a

* Private practice, North Harrow, United Kingdom.

Irfan Ahmad, BDS

The Ridgeway Dental Surgery
173 The Ridgeway,
North Harrow, Middlesex, HA2 7DF
United Kingdom. Figure 1. A model demonstrates horizontal reference lines in the facial
view: violet = hairline, orange = ophiach (eyebrow) line, yellow =
Tel: (011) 44-181-861-3535 interpupillary line, green = interalar line, and blue = commissural line.
Fax: (011) 44-181-861-2517 The red vertical line is the facial midline.

Pract Periodont Aesthet Dent 1998;10 (7):813-822 813

Practical Periodontics & AESTHETIC DENTISTRY

At the facial distance of focus, the dentition appears white

and straight. Upon closer examination, however, the teeth Rickett’s E–plane
are not straight but exhibit distinct proportions, characteri-
zations and embrasures.
The frontal and sagittal aspects are significant when
analyzing the face. From the frontal aspect, numerous 4 mm
landmarks can be used to guide the aesthetic restoration
(Figure 1). Several horizontal reference points are dis-
cernible, including the hair, ophiach, interpupillary, inter- 2 mm
alar and commissural lines. These parallel lines create
horizontal symmetry and act as cohesive forces to unify
the facial composition. The facial midline is perpendicu-
lar to these lines and opposes their cohesiveness. The
Figure 3. Rickett’s E-plane is drawn from the tip of the nose
cohesive forces are paramount in the achievement of to the chin. Accepted norms for the distance of the upper
pleasing aesthetics; the deviation of the facial midline and lower lips to this line are 4 mm and 2 mm, respectively.

(segregative forces) is secondary and varies in many indi-

viduals without a deleterious effect. As opposed to the
orientation of one single line, it is the general parallelism
of the horizontal lines that is important.2
The interpupillary line is used as a reference for the
occlusal and incisal plane orientations. While the other
horizontal lines can be eschewed and do not act as defini-
tive references, they are useful accessories. The incisal
edges of the anterior teeth should be parallel to the inter- Upper lip length

pupillary line and perpendicular to the facial midline. A tilt

in the incisal plane may be attributed to either dental or
skeletal factors; the dental factors include attrition, different
patterns of eruption, and periodontal disease. If the latter
Figure 4. The LARS factor to determine the amount of tooth
exposure at rest: Lip length — the linear measurement of
the upper lip. A medium lip length is depicted.

Nasolabial angle
(golden highlights) are eliminated, then the tilting could be caused by a slanted
maxilla. It is vital to determine which factor is responsible
for the misalignment of the incisal plane, as this will have
a profound impact on the proposed treatment plan.
From the sagittal aspect, the horizontal lines also
reinforce the cohesiveness of the profile. The nasolabial
angle (Figure 2) and Rickett’s E-plane must also be con-
sidered in this plane (Figure 3).3 The former is an angle
formed by the intersection of two lines using the nose and
lips as reference points. In males this angle ranges from
Figure 2. The nasolabial angle (golden highlights) is that formed by
90° to 95°; in females it ranges from 100° to 105°.
the intersection of two lines, using the base of the nose and the upper
lip as reference points. Rickett’s E-plane is a line drawn from the tip of the nose

814 Vol. 10, No. 7

 Ahmad

than 4 mm, a prominent maxillary anterior dental seg-

ment is indicated. Spear has termed this analysis of facial
profile as “facially generated treatment planning.”4

Dentofacial Composition
The second component in anterior dental aesthetics is the
dentofacial composition (ie, orofacial view). The constit-
uents of this element are the oral orifice, the highly vascu-
larized red lips, and the teeth, which act as a gate to the
oral cavity. The color contrast between the lips and the
teeth of the patient also contributes to the dentofacial
composition. The optimal aesthetic appearance of this
view is determined by several factors, including static and
Figure 5. The LARS factor to determine the amount of tooth
exposure at rest: Age — an elderly individual showing dynamic muscular positions.
only the lower incisors.

Static
In the static position, the lips are slightly parted, the teeth
are out of occlusion, and the perioral muscles are relaxed.
In this state, four factors influence tooth exposure: lip
length, age, race, and sex, known as the LARS factor
(Figures 4 through 7).5 The amount of tooth exposure
at rest is predominantly a muscle-determined position
(Table). The length of the upper lips can vary from 10 mm
to 36 mm; individuals with a long upper lip exhibit more
of their mandibular rather than maxillary dentition.
Age is the second component of the LARS factor
which, in a manner similar to lip length, influences the
amount of tooth visibility. The amount of maxillary incisor
Figure 6. The LARS factor to determine the amount of tooth tooth display is inversely proportional to the age of the
exposure at rest: Race — black patients typically reveal patient; alternately, the amount of mandibular incisor dis-
less tooth exposure than white patients.
play is directly proportional to increasing patient age.
People age at differing rates, since aging is a multifac-
to the chin prominence. Accepted norms for the distance torial phenomenon and can be described as programmed,
from the upper lip to this imaginary line is 4 mm, while
that for the lower lip is 2 mm. Using the nasolabial angle
Table
and the measurements of the Rickett’s E-plane, the pro-
trusion or retrusion of the maxilla can be ascertained. Upper Lip Length in Relation to Anterior Tooth Exposure

If the nasolabial angle is less than 90° and the distance Upper lip Exposure of Exposure of
length central upper central lower central
of the upper lip to the E-plane is greater than 4 mm, the Upper Lip incisor (mm) Incisor (mm) incisor (mm)
maxilla is prominent and a convex facial profile results. Short 10 -15 3.92 0.64
In this example, the placement of less dominant maxillary Medium 16 -20 3.44 0.77
anterior restorations should be considered. If a concave Medium 21 -25 2.18 0.98
Long 26 -30 0.93 1.95
profile is present (ie, nasolabial angle is greater than 90°)
Long 31 -36 0.25 2.25
and the distance of the upper lip to the E-plane is less

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Practical Periodontics & AESTHETIC DENTISTRY

pathological, and psychological. In youth, the process

of destruction and formation of cells is in a state of equi-
librium. With advancing years, increased destruction
and reduced replacement of body tissues occurs. This
change is triggered by an unknown internal factor.
Pathological aging is caused by diseases of the oral
environment, and results in the accelerated degradation
of tissues. For example, if anterior teeth are lost due to
refractory periodontitis, the nasolabial grooves develop
prematurely. Emotional and personal traumas may cause
changes in the psyche that manifest themselves as psy-
chological aging. The end result of aging is reduced
Figure 7. The LARS factor to determine the amount of tooth exposure
tonicity of the orofacial muscles and laxness of tegu- at rest: Sex — females show nearly twice the number of maxillary
mental relief in the lower third of the face. This causes the teeth than males.

formation of labial, nasolabial, and mental grooves and

ridges. The loss of elasticity and tooth support (gingival
two thirds of the maxillary incisor) of the upper lip accounts
for less maxillary and more mandibular incisor display at
rest. Attrition is another factor in the aged that contributes
to a reduced tooth display.
The last two determinants of the LARS factor are race
and sex. In white, Asian, and black patients, increased
mandibular and decreased maxillary tooth display are
evident, respectively. For gender, females (3.40 mm) dis-
play nearly twice the amount of tooth as compared to
males (1.91 mm).5 Each patient must be assessed accord-
ing to the LARS factor prior to the final determination of
Figure 8. Coincidence of the incisal plane (green) with the commis-
tooth exposure at rest, eg, an increased maxillary tooth sural line (blue). The yellow line depicts the maxillary dental midline.
exposure is indicated for young females, while the oppo- Since the right corner of the lips is higher than the left side, a lack of
lip symmetry results.
site is true for older males.

Dynamic
The dynamic position of the dentofacial composition is
characterized by the extent of tooth exposure during a
smile, and varies according to the degree of contraction
of the facial muscles, the shape and thickness of the lips,
the skeletal makeup, and the shape and size of the
dental elements. While horizontal symmetry is the most
important factor in the facial composition, it is radiating
symmetry that takes precedence in the dentofacial view.
The latter can be defined as an object having a central
point from which the right and left sides are mirror images.1
The fulcrum in this view is the maxillary dental midline, Figure 9. It is not necessary for the facial midline (red) to coincide
with the maxillary dental midline (yellow) to achieve aesthetic
from which the right and left maxillary anterior teeth should approval. The blue is the commissural line.

816 Vol. 10, No. 7

 Ahmad

be balanced mirror images. Due to differing rates of wear

and attrition of the incisal edges, this is uncommon. Lack
of radiating symmetry is not crucial, as long as there is
balance on the right and left sides of the anterior dental
segment. The incisal plane and commissural lines should
coincide to act as cohesive forces, while the dental mid-
line of the patient is the segregative force giving the com-
position interest (Figure 8).
Placement of the dental midline has evoked con-
siderable controversy in the dental literature. One theory
states that the maxillary dental midline should coincide
exactly with the labial frenum and the facial midline as
Figure 10. Attrition of maxillary anterior teeth on a maxillary denture
with lack of parallelism with the curvature of the lower lip. it does in 70% of the population,6 while another states
that the placement of the midline exactly in the center
may contribute to a sense of artificiality.7 The mandibu-
lar midline should not be used as a reference point, how-
ever, since it does not coincide with the maxillary midline
in 75% of all cases.8 If a dominant central point of focus
exists (eg, a maxillary median diastema), then the mid-
line should be placed with this focal point as the fulcrum.
A second reason for placing a vertically aligned midline
precisely in the center may be to detract attention from
asymmetries and disharmonies of the face. Alternately, a
slightly displaced dental midline (in relation to the facial
midline) is not detrimental to aesthetic approval (Figure 9).
The smile line is an imaginary line that extends from
the incisal edges of the maxillary incisors and is parallel
Figure 11. Replacement denture for case shown in Figure 10 with
correct orientation of the incisal plane to coincide with the lower to the curvature of the lower lip. A relationship between
lip curvature. the incisal table and the lower lip is often compromised
due to wear and attrition ( Figure 10), but should be
restored when possible ( Figure 11). The anterior and lat-
eral negative spaces act as a border to the dental ele-
ments, while the lips represent the frame. Anterior negative
space is evident during speech and laughter, while the
bilateral negative spaces can be observed during broad-
cast smile. These negative spaces provide cohesiveness
to the dentofacial composition and have been demon-
strated to be in the golden proportion to the anterior den-
tal segment.9 The perfect smile occurs when the maxillary
anterior dentition is in line with the curvature of the lower
lip, the corners of the lips are elevated to the same height
on both sides of the mouth (smile symmetry), and bilateral
Figure 12. The ideal smile depicts lip symmetry, coincidence of the negative spaces separate the teeth from the corners of
incisal plane with curvature of the lower lip, the gingival margins of
the maxillary centrals are barely visible, correct anterior to posterior the lips (Figure 12).
progression, and bilateral negative spaces.

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Dental Composition
Golden
The dental composition consists of the dental elements Proportion

proper: the size, shape, and intra- and interarch rela- Golden Proportion
Formula:
tionships require evaluation. Tooth size is determined by S L 2
— = —— = —— = 0.618
measuring the incisogingival length and dividing it by its L S+L 1+ 5

mesiodistal width. Researchers have attempted to geo- Golden Proportion

Calculation:
metrically link the width to race, gender, bizygomatic
3.44 5.56 2
width,10 and size of the face, while Rufenacht has pro- —— = —— = —— = 0.618
5.56 9 1+ 5

posed morphopsychological determination of the ideal

Parts: Whole (S+L) Larger (L) Smaller (S)
Linear mesiodistal width: 9 mm 9 mm  0.618 = 5.56 mm 
proportion and has suggested that the width of the cen- 5.56 mm 0.618 = 3.44 mm
Ratios: 1.618 1 0.618
tral incisor should be considered constant throughout life.1 Whole = Larger + Smaller: 9 mm = 5.56 mm + 3.44 mm
Since the research is inconclusive, a clinician may select
Figure 14. The Golden Proportion representation.
either theory. Nevertheless, general guidelines must be
followed to achieve aesthetic dimension. The width/
length ratio of the central incisor should range from 0.75
to 0.8; lower values create a long narrow tooth, while
values greater than this range result in a short wide tooth
(Figure 13). Secondly, the central incisor should be the
dominant element in the anterior dental composition. The
vertical overbite is the final element that must be addressed
in relation to speech. In addition to these fundamental
principles, subtle variations can be introduced to account
for sex, race, morphopsychological, and facial factors.
The morphology of the maxillary teeth has also been
the subject of numerous studies including the correla-
tion to the shape of the face, age, and soft/hard tissue
landmarks,11-14 most of which have proved inconclusive. Figure 15. Axial inclination — ultraviolet photography exhibits the
incisal tips of the maxillary anterior six teeth converging mesially.
The morphology of teeth is determined by heredity and
the clinician should, when feasible, obtain pictures of
patients’ relatives to aid in the determination of the defin-
itive shape of the teeth. If no records are available, age,
sex, race, and personality should be considered. Youthful
teeth should have sharp, unworn incisal edges, and the
central incisors should dominate the composition and be
in harmony with the lateral and canine teeth.
Tooth-to-tooth relationship is the next point to con-
sider. It was the Greeks who tried to formulate beauty as
an exact mathematical concept. They believed that beauty
could be quantified and represented in a mathematical
formula. This led Pythagoras to conceive the Golden
Proportion (1/1.618 = 0.618), and Plato, the Beautiful
Proportion (1/1.733 = 0.577). Both concepts state that
Figure 13. The width/length ratio of 3 maxillary central teeth: the blue
a shape or object with specific proportions is perceived
tooth has a ratio of 0.9 and is short and wide; the green tooth is 0.6
and appears long and narrow. The red has the correct ratio of 0.75. as having innate beauty. The most widely used concept

818 Vol. 10, No. 7

 Ahmad

The axial inclination of the maxillary anterior teeth is

aligned so that the incisal edges converge mesially. It is
unclear why a mesial (as opposed to a distal) inclination
invokes a sense of aesthetic approval (Figure 15). The
contact points of the anterior dental segment coincide with
the incisal edges and the curvature of the lower lip, enhanc-
ing the cohesiveness of the dentofacial composition.
Incisal embrasures have a distinct appearance that
depends on age and sex. An increase in the embrasure
angle from the maxillary central incisor to the canine can
be observed in virgin teeth following eruption (Figure 16).
Pronounced embrasures are a feature of youth and femi-
Figure 16. Youthful teeth demonstrating sharp, unworn incisal edges
with an increasing incisal embrasure angle progression from the cen- ninity; shortened, worn edges convey advancing age and
tral incisor to the canine. masculinity (Figure 17). The clinician should be guided by
patient preferences, age, and gender prior to the deter-
mination of embrasure angles.
The buccolingual thickness of teeth varies; for exam-
ple, the maxillary central incisor has a range between
2.5 mm to 3.3 mm.2 The latter is measured with a width
gauge at the juncture of the middle third and incisal third
of the tooth (Figure 18). If a reading of more than 3.5 mm
is apparent, then overcontouring of the prosthesis should
be suspected. This is generally due to underpreparation
by the clinician, leaving the laboratory technician with
inadequate space for the porcelain layer buildup and
resulting in a bulbous crown. Teeth that require crown
Figure 17. Aged teeth reveal attrition of incisal edges and inconspicu- restorations and have a thickness of less than 2.5 mm may
ous incisal embrasure angle progression.
require adjunctive endodontic therapy to achieve the
desired aesthetics.
in dentistry is that of the Golden Proportion, whose for-
mula is as follows:
S/L = L/(S + L) = 2/(1 + 5) = 0.168
where S is the smaller and L the larger part. The unique-
ness of this ratio is that when applied by three different
methods of calculation (linear, geometric, and arithmetic),
the proportional progression from the smaller to the larger
to the whole part always produces the same results
(Figure 14).9,15 Other researchers have indicated that in
reality this Golden Proportion is not always evident, and
variations are often apparent.16 If a clinician is to use the
0.75 ratio as a norm for the central incisor dimensions,
then a progressive application of this ratio, from the central-
Figure 18. Ceramic crown on die indicates that buccolingual thickness
lateral-mesial aspect of the canine tooth, will create an
is measured at the juncture of the middle third and incisal third of an
aesthetic composition. anterior tooth (green line).

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Practical Periodontics & AESTHETIC DENTISTRY

Figure 19. Correct angulation of the maxillary teeth that Figure 22. Up to 3 mm of gingival exposure (white line) is
contact with the mucosal part of the lower lip during the f aesthetically acceptable during a smile. The green line
and v sounds of speech. represents the incisal plane.

In the sagittal plane, during f and v sounds of speech,

the maxillary incisors should contact the inner mucosal sur-
face of the lower lip (Figure 19). If these teeth touch the
cutaneous portion of the lower lip for the aforementioned
reasons, an overcontoured restoration is evident. Lack of
contact with the lower lip is due to attrition or incorrect
angulation of the maxillary incisors, and subsequent restora-
tions should correct this, in accordance with providing
adequate anterior guidance without impediment to speech.

Gingival Composition
Figure 20. Inflammation of gingival margin around defec- Gingival contour follows the underlying bone architec-
tive crown on tooth #8(11) masking the gingival margin ture; a scalloped contour is associated with close root
zenith.
proximity, while a shallow appearance is evidence of
divergent roots and/or diastemata. The gingival zenith
is the most apical aspect of the free gingival margin and
is located distally for the maxillary central incisor and
canine to the long axis of the tooth. The gingival zenith
for the lateral incisors is in a direct line to the long axis
of the tooth. This zenith can be compromised by poor
dentistry (Figure 20), but can be reestablished by replac-
ing the defective restoration (Figure 21).
Extension of the free gingival margin in an apical
manner from the contact point to the attached gingiva
forms the interdental papilla. Following recession or
periodontal/iatrogenic insult, the gingival embrasures
become visible and form “black triangles.” Numerous
Figure 21. The gingival margin zenith (distal to the long
techniques for the preservation and restoration of the inter-
axis of the central) is apparent following replacement of the
defective crown on tooth #8(11) (compare with Figure 20). dental papilla have been described,17-19 and the clinician

820 Vol. 10, No. 7

 Ahmad

Gingival Aesthetic Line (GAL)

GAL Angle
GAL Angle >45˚<90˚
GAL

Maxillary Dental Midline Maxillary Dental Midline

Figure 23. Definition of the Gingival Aesthetic Line (GAL) Figure 24. GAL Class I. Note the position of the lateral
and GAL Angle. incisor in relation to the GAL.

must fill these open gingival embrasures with papillae in

order to achieve an optimal aesthetic result.
The gingival margins of the maxillary central incisor GAL Angle
>45˚<90˚
should be at the same height and symmetry during a GAL
relaxed smile. Gingival exposure of 3 mm above the cer-
vical margins of the teeth is aesthetically acceptable
(Figure 22)2; greater exposure results in a “gummy” smile
and requires correction. Treatment modalities depend on
the type of pathosis, eg, hyperplastic gingivae require
gingivectomy or crown lengthening; recession can be
corrected by cosmetic periodontal plastic surgery using Maxillary Dental Midline

guided tissue regeneration techniques; overeruption by Figure 25. GAL Class II. In this circumstance, the lateral
orthodontic intrusion; deficient pontic sites by ridge aug- incisor often overlaps the central incisor.

mentation procedures; and skeletal abnormalities with

orthognathic surgery.
One significant feature of gingival aesthetics is its
contour progression from the incisors to the canines. The
gingival aesthetic line (GAL) can be defined as a line join- GAL Angle
= 90°
ing the tangents of the gingival margin zeniths of the cen-
GAL
tral incisor and the canine. The GAL angle is formed at
the intersection of this line to the maxillary dental midline
(Figure 23). Assuming a normal width/length ratio,
anatomy, position and alignment of the anterior dental
segment, four classes of GAL can be described:
• Class I — The GAL angle is between 45°
and 90° and the lateral incisor is touching or Maxillary Dental Midline
below (1 mm to 2 mm) the GAL (Figure 24).
Figure 26. GAL Class III. The canine, lateral incisor, and
• Class II — The GAL angle is between 45° and
central incisor are positioned below the GAL.
90° but the lateral incisor is above (1 mm to

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Varying GAL classes may be displayed simultane-

ously in a single patient (Figure 28). The objective of the
clinician is to restore the gingival contour to a GAL Class
I, II, or III in order to avoid aesthetic reprisal.

Conclusion
The study of aesthetics is a combination of the numerical
and psychological aspects of beauty. Dental aesthetics
are realized by the adoption of a schematic approach,
giving due consideration to the facial, dentofacial, den-
tal, and gingival compositions. The fundamental geo-
metric laws of aesthetics and the patients’ desires must
Figure 27. GAL Class IV exhibits a lack of ordered gingival
contour progression from the central incisors to the canines. be considered before arriving at a definitive aesthetic
treatment plan. The prescription, while conforming to the
laws of nature, should also try to incorporate the creative
and artistic skills of the clinician and technician. The com-
pleted work should be unique and bear the signature of
the operators, and not merely be a facsimile based on
dogmatic principles.

References
1. Rufenacht CR, Fundamentals of Esthetics. Carol Stream, IL:
Quintessence Publishing; 1990:1-20.
2. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics.
Carol Stream, IL: Quintessence Publishing; 1994:1-15.
3. Levin JB. Esthetic diagnosis. Curr Opin Cosm Dent 1995;3:9-17.
4. Spear F. Facially generated treatment planning: A restorative
viewpoint. American Academy of Esthetic Dentistry, 16th Annual
Meeting, Santa Barbara, CA; August 8, 1991.
5. Vig RG, Brundo GC. The kinetics of anterior tooth display.
Figure 28. Two classes of GAL are often apparent in a J Prosthet Dent 1972;39:502-504.
single mouth: the right side of the patient shows a 6. Heartwell CM Jr. Syllabus of Complete Dentures. Philadelphia,
GAL Class I, while on the left a Class II is evident. PA: Lea & Febiger, 1968.
7. Dental Office Procedures, Swissedent Foundation, CA; 1990.
8. Miller EL, Bodden WR Jr., Jamison HC. A study of the relationship
of the dental midline to the facial median line. J Prosthet Dent
2 mm) the GAL and its mesial part overlaps 1979;41:657-660.
the distal aspect of the central incisor. This situ- 9. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent
1978;40:244-252.
ation is often observed in Class II angles or 10. House MM, Loop JL. Forum and Colour Harmony in the Dental
Art. Whittier, CA: MM House, 1939.
pseudo-Class II conditions, and adds variety 11. Williams JL. A new classification of human tooth forms with a
special reference to a new system of artificial teeth. Dent Cosmos
to the dental composition (Figure 25). 1914;56:627.
• Class III — The GAL angle equals 90°, and 12. Frush JP, Fisher RD. How dentinogenic restorations interpret the
sex factor. J Prosthet Dent 1956;6:160-172.
the canine, lateral, and central all lie below 13. Frush JP, Fisher RD. How dentogenics interprets the personality
factor. J Prosthet Dent 1956;6:441-449.
the GAL (Figure 26). 14. Frush JP, Fisher RD. The age factor in dentogenics. J Prosthet Dent
1957;7:5-13.
• Class IV — The gingival contour cannot be 15. Lombardi RE. The principles of visual perception and their clini-
assigned to the aforementioned classes. The cal application to dental esthetics. J Prosthet Dent 1973;29(4):
358-382.
GAL angle can be acute or obtuse. A myriad 16. Woelfel JB. Dental Anatomy: Its Relevance to Dentistry, 4th ed.
Philadelphia, PA: Lea & Febiger, 1990.
of conditions cause gingival asymmetries, 17. Beagle JR. Surgical reconstruction of the interdental papilla: Case
report. Int J Periodont Rest Dent 1992;12(2):145-151.
including recession, altered patterns of erup-
18. Lie T. Periodontal surgery for the maxillary anterior area. Int J
tion, loss of interdental papillae, clefts, and Periodont Rest Dent 1992;12(1):73-82.
19. Allen P. Use of mucogingival surgical procedures to enhance
high frenal insertions (Figure 27). esthetics. Dent Clin North Am 1988;32(2):307.

822 Vol. 10, No. 7

CONTINUING EDUCATION
(CE) EXERCISE NO. 25 CE 25
CONTINUING EDUCATION

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and
complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip
answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instructions,
please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article “Geometric consid-
erations in anterior dental aesthetics: Restorative principles” by Irfan Ahmad, BDS. This article is on Pages 813-822.

Learning Objectives:
This article reviews the geometric guidelines that comprise the fundamental elements of facial composition and proper
anterior aesthetics. Upon reading and completing this article, the reader should have:
• An understanding of the scientific principles used to develop aesthetic restorations.
• An improved ability to develop treatment plans that address varying clinical conditions.

1. Which of the following facial reference lines act 6. Which of the following decides the morphology
as a segregative force in the facial composition? of the teeth?
a. Interpupillary line. a. Gender.
b. Interalar line. b. Personality.
c. Midline. c. Shape of face.
d. Hairline. d. Heredity.

2. Which facial line is used to determine the 7. In the author’s opinion, which of the following
angulation of the incisal plane? should be used to finalize the tooth-to-tooth
a. Commissural line. width progression from the central to canine?
b. Hairline. a. Golden Proportion ratio of 0.618.
c. Ophiach line. b. Beautiful Proportion ratio of 0.577.
d. Interpupillary line. c. A ratio of 0.75.
d. None of the above.
3. The nasolabial angle is used to assess the
prominence of: 8. Which of the following buccolingual thicknesses
a. The mandible. of a central incisor may require adjunctive
b. The maxilla. endodontic therapy to achieve optimal aesthetics?
c. The nose. a. 3.5 mm or less.
d. The chin. b. 3.3 mm or less.
c. 2.8 mm or less.
4. The LARS factor is used to finalize: d. 2.5 mm or less.
a. Tooth exposure during a smile.
b. Tooth exposure at rest. 9. The zenith of the gingival margin for the
c. The mandibular incisor width. maxillary lateral incisor is:
d. The maxillary incisor width. a. In line with the long axis of the tooth.
b. Distal to the long axis of the tooth.
5. During a smile, which factor causes the most c. Mesial to the long axis of the tooth.
aesthetic reprisal? d. In line with the horizontal axis of the tooth.
a. Maxillary dental midline is not coincident
with the facial midline. 10. Which of the following GAL angles is aesthetically
b. Maxillary dental midline is not coincident acceptable?
with the mandibular midline. a. 30° to 44°.
c. Incisal edges of maxillary teeth do not b. 45° to 90°.
coincide with lower lip curvature. c. 90° to 110°.
d. Lack of radiating symmetry. d. Greater than 110°.

824 Vol. 10, No. 7