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Theory, practice & design rules

Anteriores:
Natural & Beautiful Teeth
Dr Jan Hajt, Munich/Germany
Our implant patients are ever more demanding. Whereas dental implantology used to concentrate almost exclusively on complication-free implant healing, implantological practitioners now increasingly find themselves confronted with the special
requirements of the aesthetic zone. Sophisticated patients expect near-perfect copies of their red and white aesthetics.
All restorations, including implant-supported restorations, should conform to natures rules. This is not an easy endeavour, as
even experienced implantologists will often have to admit. The success of a restoration will depend on the treatment provider
mastering not only the implantological discipline per se, but also the rules of facial harmony and anterior aesthetics.
These have been summarized in an ingenious way by Dr Jan Hajt from Munich in his new book entitled Anteriores: Natural &
Beautiful Teeth (German title: Anteriores natrliche schne Frontzhne). We are reprinting for you a short excerpt from this work.

Incisal-edge lines
Relationship between the incisal-edge
line and the lower-lip line (smile arc)
D. M. Sarver proposed to define the relationship
between the curvature of the upper incisal-edge line
and the curvature of the lower lip in a smile as the
smile arc. According to Sarver, these two lines are in
agreement in an ideal smile, or, to borrow Sarvers
term,consonant. A flattened incisal-edge line, due to
age or abrasion, is non-consonant. These terms are
important and describe the situation very well in that
consonance is quite distinct from strict parallelism.
The incisal images do not have to form a harmonious arc with the lower lip, but are supposed to harmonize with it (Fig. 1). Depending on the length and
position of the canines, the resulting shape will be
either a smoothly curved arc or the typical seagullwing shape (Fig. 2). The incisal edges may touch the
lower lip completely or intermittently, but they may
also keep their distance from the lower lip. An
inverse, i.e. downward, curvature of the incisal-edge
line appears conspicuously unsightly (Fig. 3).
According to Tjan, the upper teeth will touch the
lower lip in approximately one-half of all cases. In onethird, there will be a gap between the two; in onesixth, the lower lip will slightly overlap the teeth.
Lower-lip position is a relatively reliable indicator of

Fig. 1 Incisal-edge line and lower-lip line.

canine length. In a beautiful smile, the upper canines

will either barely touch the lower lip or they will be just
slightly covered by it. Long canines protruding on the
outside of the lower lip tend to look unbecoming
(Fig. 4). Care must also be taken to ensure that the
lengths of the canines harmonize with those of the
first premolars, since the latter are aesthetically relevant.
A straight incisal-edge line, with all incisal edges at
the same level, indicates an abraded or aged denti-

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Fig. 2 Typical seagull-wing shape of youthful incisal edges.

Composite morph of four naturally beautiful smiles.

Fig. 3 Inverse curvature of the incisal-edge line.

This situation instinctively reminds the observer of a defect.
Fig. 4 Natural dentition with unusually long canines.

Fig. 5
The further the occlusal plane is
tilted anteriorly, the more
pronounced will be the curvature
of the incisal-edge line.
Courtesy of Ackerman.

Fig. 6
Correlation between the width of
the dental arch and the curvature
of the incisal-edge line.
Courtesy of Ackerman.

tion, an appearance that should be avoided. The

incisal edges need not necessarily form a coherent
arc; they may actually almost form a straight line
on average. But the natural appearance of the dentition is only preserved if not all of the incisal edges are
on one and the same straight line. Generally, a slightly less pronounced arc or, in more extreme cases, a
straight line is considered more fitting for a man
than for a woman. This perception is primarily based
on our intuitive experience that straight lines, angles

and edges are to be interpreted as masculine, while

arcs, curves and rounded shapes are to be interpreted
as feminine. This perception is to some extent based
on biological fact, namely that the canines are statistically longer in men than in women. However, considering all the other factors that influence a specific
incisal-edge line, a natural difference between the
sexes is improbable in this respect.
The curvature of the incisal-edge line depends primarily on the sagittal inclination of the occlusal

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Fig. 7 Smile-line ratio according to Hulsey. This ratio is

calculated based on the greatest vertical distance
between the incisal edges and the contour of the
lower lip. If the ratio is approximately 1, the curvature
is roughly identical. At a ratio of greater than 1, the
incisal-edge line is less curved than the lower-lip line.
Composite morph.

Fig. 8 A smile-line ratio of 1.12, caused by a wide-open

lower lip and relatively pronounced differences in
incisal-edge heights. The entire incisal-edge line has a
pronounced seagull-wing shape. Natural female dentition.

Fig. 9 Somewhat less pronounced and asymmetrical

seagull-wing shape of the incisal-edge line from
canine to canine. Smile-line ratio: 1.09. Natural male
dentition.

Fig. 10 Arc-shaped incisal-edge line touching the

lower lip for a lot. Smile-line ratio: 1.05. Natural
female dentition.

Fig. 11 Pronounced differences in incisal-edge heights

due to suprapositioned lateral incisors.
This is reflected by the smile-line ratio of 0.88.
Natural female dentition.

Fig. 12 Less harmonious relationship between the

incisal-edge line and the lower lip. While the incisal
edges form a harmonious arc, the lower lip describes
an inverse curvature due to the patients individual
muscle tone. This situation cannot be significantly
improved by a restorative design. Natural dentition.

plane and the shape of the dental arch (Fig. 5 and 6).
Other influential factors are the individual characteristics of tooth positions and functional patterns.
The curvature of the incisal-edge line is particularly important in connection with orthodontic therapy.
It has been reported that orthodontic tooth movements may often flatten this line.
The study by Hulsey gives us more detailed information about the aesthetic effects of different
degrees of agreement. Based on his observations

that the lengths of the canines may vary and that

they may be partially covered by the lower lip in a
smile, Hulsey excluded the canines from his analyses.
From the curvature of the incisal edges and the curvature of the lower lip immediately below the incisors, Hulsey calculated a so-called smile-line ratio,
finding that this ratio had an effect of the subjective
aesthetic impact of a smile on observers (Fig. 7 to 11).
Smile-line ratios between approximately 1 and 1.25,
i.e. perfect or nearly perfect harmony, were consid-

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Characteristics of a natural incisaledge line

Fig. 13 Typical incisal-edge line. Composite morph of 16 regular female

dentitions included in the present study.

Fig. 14 The extraoral view shows that the canine tips are slightly higher,
the lateral incisors rise higher toward the distal aspect, and the curvature
of the entire arc is more pronounced.

It is possible to describe with some precision how the

anatomical crown shapes and tooth positions in the
normal dentition work together to form the typical
upper incisal-edge line as seen in a frontal view.
Only rarely are the shapes and sizes of the two
central incisors perfectly identical in nature. Interestingly enough, this can also be seen on composite
morph images (Fig. 13). Here, tooth 21 is slightly
shorter than tooth 11. However, the more practical
approach when designing dental restorations is to
begin by ensuring identical crown lengths and identical positions of the incisal edges of the central incisors, since asymmetries near the midline tend to be
much more conspicuous optically than lateral asymmetries. In addition, very few patients desire or
approve of central asymmetries. Slight variations
should only be introduced for a very good reason,
such as in connection with protrusive movements or
facial asymmetries.
The reference plane is the selected horizontal plane.
Lateral incisors are invariably shorter than central incisors. Canine lengths may vary slightly, but the canines
should never be longer than the central incisors (Fig. 14).
Incisals edges in central and lateral incisors are
generally straight (Fig. 15). Canines in adults do not
appear pointed, but slightly abraded. Incisal corners
are more pointed mesially than distally in all teeth.
The sizes of the incisal embrasures increase in depth
and width from mesially to distally. Following tooth
widths and the shape of the dental arch, the embrasures will be continually closer. This is one of the
most important criteria for a natural vivid smile.
These triangular embrasures must never be of the
same size, nor equidistant.

Positions of the edges of the central incisors relative to the upper-lip line at rest
Fig. 15 Geometry of the incisal-edge line.

ered much more beautiful than higher ratios indicating flatter curvatures of the incisal edges. Inverse curvatures of the lower lip are encountered only in very
rare cases. These will also result in non-consonance
of the two contour lines (Fig. 12).
The relationship of the lower lip to the incisal-edge line
is one of those criteria that may vary greatly in relevance
depending on the particular patient type. While some
faces tolerate considerable variation, the appearance of
some patients strongly reflects even minor alterations.

When tasked with positioning a dental restoration

within the existing lip window, one of the most
important factors is the vertical position of the
incisal plane. From a strictly aesthetic point of view,
the position of the lips at rest can serve as a reliable
reference. Since, as has been shown, the degree to
which the lower lip can be pulled downward while
smiling and the distance between the incisal edges
and the lip can vary greatly, the lower-lip line is a less
suitable line of reference for determining the optimal
incisal position.
A methodical planning process for an aesthetic
anterior appearance should always begin by determining the positions of the central incisors. This is

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Fig. 17
Baseline situation. Tooth 11:
Endodontically
pre-treated.
Teeth 12, 21, 22:
Labially eroded
enamel, malpositioning, insufficient composite restorations.

Fig. 16 Approximately 5 mm vertical height of the

central incisors of this young female patient are
visible when her mouth is slightly opened and her lips
are relaxed. Diagnostic provisional spanning all four
incisors.
done by repeatedly letting the patient make an M
sound and observing the lips opening slightly in a
relaxed manner. The length of the visible crown will
decrease with age. While women below 30 expose an
average 3.5 mm and men expose an average 2 mm
(called reveal or display), this value is reduced continuously and reaches 0 mm in over 60-year-olds.
This is caused both by the attrition of the incisal
edges and an increasingly lower upper-lip line.
These numbers are good guidelines for creating a
youthful smile. Of course, they are only a rule of
thumb, and factors such as lip volume, lip shape and
lip tension, but also patient preference, must be
taken into consideration.
The vertical lengths of the central incisors cannot be
viewed independently of the sagittal positions of the
incisal edges. The relationships with the lower lip and
the mandibular teeth must be taken into consideration, depending on the amount of overjet and an overall tooth position. When forming an F or V sound, the
incisal edges should slightly touch the mucosa of the
lower lip where it borders the wider aspects of the lip.
However, checking the V sound is not a very reliable
approach, since this sound is subject to great intraindividual variation. The articulation of the S sound is
much more critical. The distance between the maxillary and mandibular teeth is quite rigidly defined for
the S sound, with minimal deviations producing audible results, potentially causing comprehension problems. Most importantly, however, the lower lip must
glide smoothly past the incisal edges when the mouth
is being closed, meeting them without resistance and
without the upper incisors getting in the way. Figures
17 to 19 illustrate a patient case where a restoration
had to be completely redesigned for this very reason.
The patient had received ceramic veneers, where it is

Fig. 18 Intermediate result. Teeth 12, 21, 22:Veneers.

Tooth 11: Ceramo-metal crown. This ensemble was highly
satisfactory from an esthetic point of view.
However, the lower lip kept colliding with the incisal
edges, to the extent that redoing the restoration became
inevitable (cf. Figure 19).
Fig. 19
Final result.
An aesthetically and
functionally
acceptable
treatment
outcome.

much more difficult to anticipate the postoperative

situation than with crowns. This was compounded by
slight laboratory-induced deviations during the veneer
fabrication process. This case impressively demonstrates how little leeway we often have for making any
modifications to the anterior situation at all.
In the case of crown restorations, however, a validation of the aesthetically ideal length of the incisor for
its functional, phonetic and convert implications can
be performed easily and reliably using a correctly
dimensioned and precise diagnostic provisional (see
Figure 16). We should therefore take advantage of
this option wherever possible.

CONTACT ADDRESS:
Dr Jan Hajt
Weinstr. 4 . 80333 Mnchen
GERMANY

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Anteriores:
Natural & Beautiful Teeth
Picture Gallery
So much for our short excerpt from Anteriores: Natural & Beautiful Teeth. In addition, this book offers an
impressive picture gallery with a great variety of
images of natural teeth. While it is that dentists see
healthy natural teeth every day, the subtle differences and the sheer infinite variety of shapes will
only unfold when a large number of examples are
shown together and compared directly. This is why
this book presents a selection of naturally beautiful

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anteriors in the form of a colour atlas. The smiles are

presented systematically based on gender and the
approximate regularity of tooth position. This collection can be used as a primer for aesthetic planning
and for the fabrication of anterior restorations. It can
also support the communication between dentists,
patients and dental technicians. One final example
will demonstrate this.

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