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Anterior Teeth Esthetics in Prosthodontics and Restorative Dentistry

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 Journal of International Dental and Medical Research ISSN 1309-100X Anterior Teeth Esthetics
http://www.jidmr.com Chu Thi Quynh Huong et al

Anterior Teeth Esthetics in Prosthodontics and Restorative Dentistry

Chu Thi Quynh Huong1* Trinh Hai Anh2,3, Trinh Dinh Hai3

1. Department of Prosthodontics, Ha Noi National Hospital of Odonto-stomatology, Hoan Kiem District, Hanoi 100000, Vietnam.
2. Department of Implantology, Ha Noi National Hospital of Odonto-stomatology, Hanoi, Vietnam.
3. VNU School of Medicine and Pharmacy, Vietnam National University, Hanoi 100000, Vietnam.

Abstract
Dental esthetics is an important concern for patients seeking prosthodontic restorative dental
treatment. Beauty has specific proportions of face and teeth having optimal symmetry, height, and
width. Analyses of facial and dental parameters are necessary for medical science and dentistry.
The selection of teeth has a vital role in the restoration of esthetics in dental treatment. The aim
of this review is to present an overview of facial and dental esthetics and present various aspects of
dental esthetics including facial esthetics, dental esthetics, and biomaterials for esthetic restoration.
The anterior teeth' shape and size play an important role in developing pleasing dental and facial
esthetics. Facial and dental aesthetics are enhanced if there is a golden proportion (GP) between
the maxillary anterior teeth. According to the GP of teeth, the visible width of the lateral incisor to
the central incisor is 62% of the, and the visible width of the canine to the lateral incisor is 62%. In
anterior esthetic restoration, it is important to know the various esthetic elements that make teeth
and face harmony and symmetry.
The restorative biomaterials that can be used for the esthetic restoration of anterior teeth are
ceramic/zirconia, composite, PEEK, and indirect resin. At present various newer ceramic
biomaterials are being developed with various treatment modalities to produce esthetic results.
Restoration of anterior teeth with esthetic standards and considering parameters of face and teeth
helps in producing esthetic results. Porcelain veneer and dental composite restorations are esthetic
restorations and help to improve the tooth shape and color.
Review (J Int Dent Med Res 2024; 17(1): 407-413)
Keywords: Dental esthetic, facial esthetic, esthetic restoration, teeth proportion, anterior teeth.
Received date: 13 October 2023 Accept date: 28 December 2023

Introduction nasale and inferior border of the face (menton).

In addition, the face is divided into horizontal
The beauty of the face is the combination fifths consisting of the width of each eye, lateral
of features that result in pleasure to the mind. canthus to the lateral hairline, and inter-canthal
The physical appearance of the face greatly distance.
affects the confidence of the patient. The ideal Facial and dental esthetics are a major
face is proportionate and attractive. Hence, requirement of prosthetic and prosthodontic
beauty has specific proportions of face and teeth treatments.1, 2 Four important components of
having optimal symmetry, height, and width. esthetic dental treatments are; (a) frame and
Proportional faces are balanced in both vertical reference, (b) proportion and idealism, (c)
and horizontal portions. The face can be divided symmetry, and (d) perfective and illusion.3
into 3 distinct divisions which are also known as Furthermore, the teeth size, shape, visibility, and
the rule of thirds (upper, middle, and lower face) gingival esthetics play an important role in
from the following landmarks; the superior border restoring the esthetics in edentulous patients.4, 5
of the face is trichion (hairline), nasion, sub- Face and dental midline also play an important
role in facial esthetics.6, 7 The proportionate
anterior teeth size in prostheses results in
*Corresponding author:
Chu Thi Quynh Huong,
harmony with the overall facial appearance.
Department of Prosthodontics, Ha Noi National Hospital of Esthetic restorative treatment in anterior teeth
Odonto-stomatology, Hoan Kiem District, Hanoi 100000, should be done in ways that maximize the
Vietnam.
E-mail: [email protected] esthetic outcome. On the other way, facial
landmarks also play a vital role in the selection of

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http://www.jidmr.com Chu Thi Quynh Huong et al

teeth for the prosthetic rehabilitation of patients.8, Asia, the narrow face is a common facial type
9
The aim of this review is to present an overview compared to the average and broad face.
of facial and dental esthetics and present various Various anatomic landmarks are used to
aspects of dental esthetics including facial select the size of the anterior teeth, e.g.
esthetics, dental esthetics, and biomaterials for interpupillary line, bizygomatic width, mouth
esthetic restoration. width, and nose width.17 The is a positive
Facial Esthetics and Proportions relationship between the width of the central
Facial beauty is governed by facial incisor to the bizygomatic width and the maxillary
symmetry and proportions. Ideal proportions of central incisor width is 1/16th of the bizygomatic
the face and teeth have specific proportions, i.e., width.18, 19 A study done by al-el-Sheikh and al-
golden proportion (GP) and it has specific Athel20 in the Saudi population found a positive
proportions of 1.618 (larger to smaller) or 0.618 relationship between the inter-canine tip width
(smaller to larger).10 Still, in various populations, and nose width. Their study also showed
the GP of the face is difficult to find and the facial significant correlations between inter-alar
measurements show deviations from GP distance, inter-pupillary distance, and the width of
although the soft tissue shows facial balance.11 the six anterior teeth. In addition, significant
The face can be divided into vertical fifths differences between both sexes were found.
but very less populations show this proportion Another study by Al-Wazzan21 in the same
and show variations in facial proportions. In a population studied the correlations of inter-
study done by Milutinovic et al.12 in the Serbian canthal distance with widths of central incisors
population (24 celebrity Caucasians) and and found a significant relationship between
anonymous females (83 Caucasians), the inter-canthal distance and the 4 incisors only.
attractive celebrity females had smaller faces and They did not find correlations of inter-canthal
showed the facial fifths and thirds and most facial distance with the widths of 2 central incisors and
parameters had ideal proportions. the width of the 6 anterior teeth. Yodsuwan et
Considering the standard in treating al.22 studied the correlations of inter-alar (nose)
creates facial esthetics, TMJ health, physiologic width and inter-canine width (tip to tip) and width
health, and quality of life. In completely of the mouth and maxillary inter-canine width
edentulous patients, the facial types of the (distal to distal) and found poor correlations in the
patient have been used to select the teeth shape. Thai population. Similarly, Hasanreisoglu et al.23
The three common facial types are euryprosopic performed a correlation study between the nose
(transversely wide and broad), mesoprosopic width, inter-canine distance, and inter-canine tip
(average type), and leptoprosopic (face is distance in Turkish students and found a positive
vertically tall and transversely narrow). relationship between these measurements. Latta
The facial index is used in classifying the et al.24 studied North American edentulous
facial types and it is the ratio of naso-menton patients and also found no correlations between
height to bizygomatic width and it is used to inter-commissural width, inter-alar width, and/or
classify the faces into broad, average, and interpupillary width. Varjão and Nogueira25
narrow.13-16 Face measurements can be done by studied Brazilian subjects and also found a weak
direct or indirect methods. Direct facial correlation between inter-commissural width and
measurements can be done directly in patients distal of canines in their study.
and are a reliable method. Indirect face Dental Esthetic and Proportions
measurements can be done on photographs or The maxillary anterior teeth's shape and
videographs. Different studies show the various size play an important role in dental and facial
facial types in various populations In the esthetics.10 Facial and dental aesthetics are
Nepalese population, the majority of the facial enhanced if the widths of maxillary anterior teeth
type had narrow (69%) followed by average proportion show GP when viewed from the front.
(24%) and broad (7%).1 Similarly, in the Iraqi Moreover, according to the GP of teeth, the visible
population, the majority had narrow (80%) width of the lateral incisor (LI) to the central incisor
followed by average (16%) and broad (4%) types (CI) is 62% and the visible width of the canine to
of face.14 In the Turkish population, the majority the lateral incisor is 62%.10 Figure 1 shows the
had narrow (37.58%), average (28.33%), and GP of maxillary central and lateral incisors.
broad (34.10%) types of faces.15 Hence, in South Leven10 applied GP in medicine and dentistry,

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 Journal of International Dental and Medical Research ISSN 1309-100X Anterior Teeth Esthetics
http://www.jidmr.com Chu Thi Quynh Huong et al

especially in the perceived widths of maxillary Dental parameters for the dental esthetics
anterior teeth. The optimal dental esthetic includes
In various studies, GP was not found in various parameters for the anterior teeth. In
different populations; Turkish, North American, relation to the facial midline, the dental midline is
Jordanian, Croatian, Indian, Iranian, Brazilian, straight but can be slightly oblique.42 Smile lines
Hungarian, Malaysian, Bangladeshi, Londoners, follow the convexity of the lower lip.43 The incisal
Irish, Portuguese, Korean, Japanese, and plane is either convex, sinuous or a combination
Nepalese.1, 5, 23, 26-38 The results of teeth of both.
proportions in these studies deviated from GP. In Anterior teeth alignment can diverge in at
North America, various anterior teeth proportions least one plane.43 Central incisors are
have been proposed.31 Preston31 recommended symmetrical, slightly mesially inclined, may
66% for LI/CI instead of 62% and 84% for the overlap slightly, and are positioned more in a
CN/LI which is called Preston Proportion. facial position. Mesial tooth inclinations are more
Similarly, Ward32 gave the Recurrent Esthetic pleasing and incisal edges of the central incisors
Dental (RED) proportion for the LI/CI and C/LI may be slightly misaligned if their gingival margins
and the ratios ranged from 60% to 80% but he are not level. The lateral incisors may differ
preferred a 70% ratio. Furthermore, Calcada et bilaterally in inclination, rotation, and shape. The
al.36 did a study in the Portuguese population and labiolingual inclination of the canines can be
found that the anterior teeth proportions showed slightly asymmetrical.
a 66% Preston proportion rather than the GP and Esthetic Keys
the RED proportion. The are main five esthetic in dentistry
keys given by Kokich et al.44 and includes the
following; midline, occlusal plane, incisal edge
position, incisal plane/smile line, and gingival
level.
Midline
In order to have good dental esthetics, the
dental midline should be straight. But people often
don´t notice the facial/dental midline
discrepancies. Midlines don´t need to be in the
center of the face but they must be straight. The
central incisors should be symmetrical.
Occlusal Plane
The occlusal plane is an imaginary line
Figure 1. Golden proportion (GP) of teeth. that passes the incisal edges of the incisors and
then touches the cusp tips of the posterior teeth.
Another important ratio of anterior teeth is Ideally, the extension of the incisal plane should
the golden standard (GS) where width/height be in harmony with the lower lip.
(W/H) ratios of maxillary anterior teeth are 80%. Incisal Edge Position
However, the W/H ratios of maxillary anterior teeth Incisal edge position is important and it is
may vary from 75-85%.39, 40 Tsukiyama et al.41 necessary to evaluate the incisal plane and
studied the W/H ratios of maxillary anterior teeth occlusal plane relationship. Ideally, the occlusal
in 157 Asians and 142 Caucasians and they and incisal planes are on the same level.
found that there was a difference in the W/H Incisal Plane/ Smile Line
ratios of all maxillary anterior teeth between There should be harmony between the
Asians and Caucasians. The anterior maxillary incisal line and the curvature of the lower lip.45 In
teeth in Asians are more slender with greater addition, the smile line follows the convexity of
W/H ratios compared to those in Caucasians. the lower lip.
Finally, for esthetic rehabilitation, the GP in the Gingival Level
anterior teeth width ratios and the W/H ratios of Ideally, the gingival margins of both
the maxillary anterior teeth serve as a useful central incisors are symmetrical. Need to
guide in the establishment of an attractive smile. determine tooth size/position first. Using gingiva
as a reference should be avoided to position

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 Journal of International Dental and Medical Research ISSN 1309-100X Anterior Teeth Esthetics
http://www.jidmr.com Chu Thi Quynh Huong et al

incisal edges. Gingiva shows a reduction with The restorative biomaterials that can be
eruption or recession. Tooth asymmetry is more used for the esthetic restoration of anterior teeth
noticeable than gingival asymmetry. are ceramic/zirconia, composite, PEEK, and
Figure 2 shows the intraoral figure of a indirect resin. At present various newer ceramic
woman with esthetic problems; midline shift and biomaterials are being developed with various
unesthetic teeth which needed esthetic dental treatment modalities to produce esthetic results.
treatments to increase the esthetic of teeth.46 The porcelain restorations achieve good esthetic
Figure 3 shows an intraoral view of a male results with a more balanced harmony.48 The use
patient with esthetic teeth with ideal functional of digital technologies such as 3D printing and
and biological conditions.47 intraoral scanners has simplified and resulted in
increased esthetic results.48-51

Figure 2. The teeth of a female showing a

midline shift in the mandibular arch, and crown
height discrepancy in anterior teeth. Surgical
crown lengthening and fixed prosthodontic
treatments were done to improve the esthetics.
Adapted with permission from Ref.46

Figure 4. Teeth of a 31-year-old male with

esthetic teeth with ideal functional and biological
conditions. (a) Pretreatment photographs, (b)
Figure 3. Teeth of a 31-year-old male with digital smile design, (c) moke-up, (d) tooth
esthetic teeth with ideal functional and biological preparation, (e) ceramic veneer, and (f)
conditions. Adapted with permission from Ref.47 cementation. Adapted with permission from
Ref.47
Biomaterials for Esthetic Restorations
Human teeth are characterized by Ceramic/ Zirconia
various shades from opaque to translucent Anterior porcelain veneer restorations
areas. Hence, when selecting the shade of teeth can restore the teeth's shape and color with good
which involves a basic shade selection and the shape and create contact between adjacent teeth
identification of opaque and translucent areas. A to achieve horizontal stability for the dental arch
balance of the opaque and translucent shades is and bring the patient's esthetics. Porcelain
an important factor in obtaining a good esthetic veneers and crowns can restore teeth
outcome. discolorations from various causes such as
trauma, fluorosis, tetracycline, etc. They are

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made from computer-aided design and carefully. The closer the adhesive surface is to
computer-aided manufacturing (CAD/CAM) the thin layer of cement, the less disintegration
techniques. At present, they can be fabricated in will be reduced of cement.
a single day using faster-sintering technologies Resin-based composite (RBC)
and producing optimal esthetics and mechanical Commercially available RBCs can
properties.52, 53 Figure 4 shows the esthetic provide esthetic restorations as they have
restoration of anterior teeth on a 31-year-old opaque and translucent materials. The opaque
male patient using ceramic restorations using a shades are used for inner restoration as dentine
digital smile design.47 or for opaque margins whereas the translucent
The use of digital technologies such as shades are used as final layers or for incisal
3D printing and intraoral scanners has simplified translucencies. Most often they are named
and resulted in increased esthetic results.48-50 “dentin” for opaque shades and “enamel” for
Figure 5 shows the anterior esthetic restoration translucent shades.57
with zirconia crowns of a 51-year-old female with RBCs have good clinical success mainly
the use of 3D printing and other digital for the Class III, IV, and diastema closure and
techniques.48 they provide excellent results with lower costs
compared to ceramic restorations. Figure 6
shows the composite restoration for the esthetic
restoration of the maxillary anterior teeth. Case 1
with factures one incisor and Case 2 with
fractured both incisors.57 Esthetic direct anterior
restorations show a success rate of 95% (Class
III) and of 90% (Class IV) after 10 years.8, 9 The
esthetic outcome of an RBC restorations
depends on various factors, i.e. the material
properties, composite opacity and translucency,
Figure 5. Anterior esthetic restoration with adhesive technique, shade selection, operator
zirconia crowns of a 51-year-old female with skills, surface finish, and biological factors.
fracture of left central incisor with the use of 3D
printing and digital techniques. Adapted with
permission from Ref 48 (a) Pretreatment
photograph, (b) 3D design of surgical guides, (c-
d) try-in of the surgical guides, (e) 3D design of
final crowns, (f) final zirconia crowns, and (g) final
zirconia crowns in patients.

Currently, ceramic materials and

technology are increasingly being improved and
widely used in clinical practice.54, 55 The oxide
porcelain is essentially zirconia oxide, this type is
poor in light conductivity, so when indicated for
front teeth is often chiseled, affecting aesthetics,
moreover, they are very hard and cannot be worn
and glued to tooth tissue, while the glass
porcelain line that overcomes this disadvantage
has the optical properties of the teeth. At present
translucent ceramic biomaterials are being
developed increasing the esthetics.56 Natural,
preserved by the chemical adhesive mechanism Figure 6. Composite restoration for the esthetic
to increase the durability of the restoration. restoration of the maxillary central incisors. Case
Furthermore, when choosing the adhesive, it is 1 with fracture of left incisor and Case 2 with
necessary to adhere to the step of coating with fracture of both central incisors. Adapted with
an anti-oxidant after attaching and polishing permission from Ref.57

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Limitations of RBC include fracture expectations of the treatment and to avoid

resistance and surface instability compared to aesthetic treatment failures.
ceramic restorations.57 But they have partially
been solved by the introduction of newer Conclusions
composites such as micro-hybrid composites, In anterior esthetic restoration, it is
nano-filled, and nano-hybrid composites. important to know the various esthetic elements
Regardless of the mechanical properties, other that make teeth and face harmony and
properties have been improved for the RBCs in a symmetry. Analyses of facial and dental
few decades, such as optical properties and parameters are necessary for medical science
biocompatibility. and dentistry. It is necessary to know the esthetic
Furthermore, the development of RBCs standards and parameters of the face and teeth.
has led the clinician to reproduce the shade and Porcelain veneer and dental composite
the translucencies of natural teeth. Different restorations are esthetic restorations and help to
layering techniques have been recommended for improve the tooth shape and color. In dentistry,
producing esthetic results.33 Composite the clinician and technician must move beyond
restoration failures (shade adjustments, shape intuitive appraisal and use fundamental esthetic
modification, o contact point augmentation) can principles to help achieve an esthetically pleasing
be repaired and can be carried out either smile also preserve their individuality.
immediately or on old restorations (secondary
caries or fractures). Acknowledgements
Social, Cultural, and Environmental
The data used to support the findings of
Factors for Dentofacial Esthetics
this study are available from the corresponding
Physical appearance is an essential
author upon request.
factor in social interaction. The face and teeth are
important elements in the evaluation of physical Declaration of Interest
appearance. Recently, there has been an
increase in interest in dental esthetics among The authors report no conflict of interest.
patients and dentists especially in prosthodontics
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Volume ∙ 17 ∙ Number ∙ 1 ∙ 2024 Page 413

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