Smile esthetics in orthodontics

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

...
 Introduction
 Historical aspects
 The

esthetic paradigm
 Records in treatment of the smile
 Tooth-lip relationships...
 Influence of

extractions on smile esthetics
 Tooth shape and smile esthetics
 Principles of cosmetic dentistry in smi...
Introduction


The importance of beauty and attractiveness
in today’s society has been well established.
 Physically att...
 Dentofacial

attractiveness is particularly
important to a person’s psychosocial
well being.
 People with a normal dent...
 During

interpersonal interactions, the
eyes primarily scan other people’s eyes
and mouths, with little time spent on
ot...


Esthetics, which is derived from the Greek word
for perception, deals with beauty and the beautiful.
 It may be divide...
 Contemporary techniques

in orthodontics
should lend objective esthetics to the entire
orofacial complex involving unity...
Esthetics in orthodontics has been
defined mainly in terms of profile
enhancement, but if you ask lay people
what an ortho...
Historical aspects
 The

study of frontal facial form dates
back to the Egyptians, who depicted
ideal facial esthetics as...
In the latter part of the 19th
century, Norman
Kingsley, the leading
orthodontist of the
era, emphasized the esthetic
obje...
Edward Angle‟s emphasis on occlusion led him to
teach that optimal facial esthetics always
coincided with ideal occlusion ...


This focus on the profile was because the
lateral cephalogram has long been the
lynchpin of orthodontic treatment plann...


Art instruction by Prof Wuerpel was an
integral part of the Angle curriculum, but it
has gradually disappeared from the...
The esthetic paradigm


Although ideal occlusion remained the primary
functional goal, it was acknowledged that the
esthe...
 Today’s

―art of the smile‖ is being driven
by the orthodontist’s ability to clinically
examine the patient in 3 dimensi...
 The

contemporary orthodontist no
longer evaluates patients in terms of
only the profile, but also frontally and
vertica...
www.indiandentalacademy.com
 Orthodontists

are the first in line in a
decision-making process that ultimately
affects a patient’s appearance for the...
 The

orthodontist must work with 2
dynamics.
A. Soft tissue repose and animation
assessed at the patient’s examination
i...
Records in the treatment of the smile
3 categories of orthodontic records
 Static records (Photographs)
 Dynamic records...
Photographs:
 In addition to the standard frontal at rest, frontal
smile and profile at rest images, Sarver and
Ackerman ...
www.indiandentalacademy.com


Dynamic recording is accomplished with digital
videography
 Digital video and computer technology enables the
clinicia...
www.indiandentalacademy.com
Direct measurement as a biometric tool
 Quantification of resting and dynamic liptooth relationships is critical to smile...
Tooth-lip relationships
Systematic measurement of resting tooth–lip
relationships virtually leads the clinician to a
quant...
Philtrum height is
measured in
millimeters from
subspinale (the base
of the nose at the
midline) to the most
inferior port...


Commissure height is
measured from a line
constructed from the
alar bases through
subspinale, and then
from the commiss...
 The

absolute linear measurement of
philtrum height is not particularly
important, but its relationship to the
upper inc...
A short philtrum in
adults results in an
unesthetic maxillary
lip line which makes
resting posture
resemble a frown.

www....
Incisor show at Rest and Smile
 The amount of maxillary incisor show at rest
is a critical parameter esthetically, becaus...
 Peck

et al (AJODO 1992) showed that the
normal display of maxillary incisors with
relaxed lips at 15 years age is 4.7 +...
 Excessive tooth

display is judged better at
rest than on smile, because lip elevation on
smiling is quite variable.
 I...
A gummy smile can be esthetic !

www.indiandentalacademy.com
 In

1992, Peck et al described how
orthodontists and surgeons are
conditioned to see high gingival smile
lines as undesi...


They noted that the biological mechanisms of
the gingival smile line are influenced by
anterior vertical maxillary exce...
 Dong et

al (Int J Prosthod 1999) compared
the age changes in maxillary and
mandibular incisor display at rest and when
...
www.indiandentalacademy.com
 The

importance of proper planning for
vertical incisal positioning in orthodontics
and orthognathic surgery cannot be
o...
Crown height


The percentage of incisor display, when
combined with crown height, helps the
clinician decide how much to...
The Smile Arc


The smile arc from the frontal view is the
relationship of the curvature of the incisal
edges of the maxi...
www.indiandentalacademy.com
 Tjan

et al (J Prosthet Dent 1984) in a
survey of young Los Angeles adults,
found that a great majority (85%) had a
maxi...
The Social Smile and the Enjoyment
Smile.


The social smile is a voluntary smile a person uses
in social settings or whe...
www.indiandentalacademy.com


What differenciates the social smile from the
enjoyment smile is not the activity of the
orbicularis oris musculature, ...





1.
2.
3.

Tarantili, Halozonetis and Spyropoulos (AJODO
2005) recorded and analyzed spontaneous smiles
in fifteen ...
 The

smiles were accompanied by display of
teeth and mouth opening, though not
consistently.
 On average, facial measur...


The smile extended over the whole face including
wrinkling around the eyes and contraction of the
orbicularis oculi mus...
 In

treating the smile, the social smile
generally represents a repeatable smile.
Sarver and Ackerman (AJODO 2003) chose...
FRONTAL DIMENSION
 To visualize and quantify the frontal
smile, Ackerman and Ackerman
(1998), developed a ratio, called t...
This patient has small smile index value with
substantial incisor display on smile.
www.indiandentalacademy.com


Frontally, we can visualize and quantify 2 major
dimensions of the smile: vertical and transverse
characteristics.
 Th...
Inadequate incisor display can be due to:
 Vertical maxillary deficiency
 Limited smile area (a large smile index),
 Sh...


Other vertical smile characteristics are the
relationships between the incisal edges of the
maxillary incisors and the ...


1.

2.
3.

Tjan and Miller (1984) described three types of
smiles acording to lip coverage of maxillary
incisors in ful...
Clinical implications for Deep Overbite correction
Average and low smile types
 Correction of deep anterior overbite can ...


The optimal vertical reference position for the
maxillary incisal edge in orthodontic treatment
planning is with relaxe...
Prior to treatment, each patient‟s tooth display
should be carefully analyzed at rest and speech,
before deciding whether ...
Reduced anterior overbite and high erupting
canines
 Use of a continuous leveling wire may overintrude the incisors into ...
Treatment of gummy smiles


The biologic mechanism of gummy smiles appears
to involve anterior vertical excess, increased...


If maxillary incisor show at rest is optimal, active
upper incisor intrusion should not be initiated.
Instead surgical ...
Treatment of most severe gummy smiles
may require maxillary superior
repositioning surgery (Le Fort I osteotomy)
along wit...
Gummy smile treated with combination of
maxillary impaction surgery and crown
lengthening

www.indiandentalacademy.com


Gummy smiles can also be treated using plastic
surgery to correct the hyperfunction of upper lip
muscles, especially by...
Use of Botox for treatment of gummy smiles.


Botulinum toxin has been under clinical
investigation since the late 1970s ...


BTX-A weakens skeletal muscles by cleaving
the synaptosome-associated protein SNAP25, thus blocking the release of acet...


Polo M (AJODO 2005) described a nonsurgical
alternative for reducing excessive gingival
display caused by muscle
hyperf...
www.indiandentalacademy.com
www.indiandentalacademy.com
Injection with BTX-A provides
effective, minimally invasive, temporary
improvement of gummy smiles for
patients with hyper...
Flattening of the Smile Arc
 Undesirable flattening of the smile arc is greatly
underestimated in orthodontics.
 Hulsey ...


Normal orthodontic alignment of the maxillary
and mandibular arches may result in a loss of
the curvature of the maxill...
 If

all patients routinely have their
maxillary central incisors placed 4.5 mm
above the incisal edge, their lateral
inc...
 Bracket

placement, with emphasis on
the goal of attaining canine guidance
may create relative intrusion of the
maxillar...
www.indiandentalacademy.com


In patients in whom excessive gingival
display on smile is noted, and for whom one
of the treatment objectives is to re...
Midline considerations


When viewing dentitions, many clinicians use
the maxillary central incisors as their esthetic
ba...
A

practical approach to locating the
facial midline references two anatomical
landmarks. The first is a point between
th...
www.indiandentalacademy.com


Whenever possible, the midline between the
maxillary central incisors should be
coincidental with the facial midline.
...
 According to

Kokich, as long as the
maxillary midline deviation is parallel to the
facial midline, even a 4mm maxillary...
Transverse characteristics
 The

transverse characteristics of the smile
in the frontal dimension are
 Arch form,
 Labi...


Arch form plays a pivotal role in the transverse
dimension of the smile. Recently, much attention
has been focused on t...


An important consideration in widening a narrow
arch form, particularly in adults, is the axial
inclination of the bucc...
Orthodontic expansion and widening of a
collapsed arch form can dramatically improve
the smile by decreasing the size of t...
Labiolingual crown inclinations:
 Generally 90% of people show the 1st or 2nd
premolar as the last tooth when smiling.
 ...
www.indiandentalacademy.com
www.indiandentalacademy.com
Buccal corridors


The transverse smile dimension is also related to
the lateral projection of the premolars and the
mola...
 They

stated that the size and shape of
the buccal corridors were not important,
as long as the buccal corridors were
no...


Only a few studies have determined the esthetic
value of the buccal corridor space.
 In 1995, Johnson and Smith found ...
In adolescents, it is often desirable to increase arch
width with rapid maxillary expansion to create
space for non-extrac...
 Arch

expansion might fill out the transverse
dimension of the smile, but 2 undesirable
side effects could result, and c...
2. When the anterior
sweep of the maxillary
arch is broadened, the
smile arc may be
flattened
 This is particularly
impor...
 Although it

may not be possible to avoid
these undesirable aspects of expansion, the
clinician must make a judgment in ...
 According to

Moore et al (AJODO Feb
2005) the esthetic values of today may
differ from those of 50 years ago.
 People ...
 The

same authors carried out a study in
which color slides of 10 smiling subjects
were digitally altered to produce
nar...
www.indiandentalacademy.com
 Analysis

showed that lay persons
considered broader smiles to be more
attractive as compared to narrow smiles.
 They c...


In another study by Roden-Johnson et al (AJODO
March 2005), smiling photographs of 20
women treated by 2 orthodontists ...


There was no significant difference in smile
scores related to BCS for all samples and for
all viewers.
 Dentists rate...
Transverse cant of the maxillary occlusal
plane.


Transverse cant can be due to differential eruption
and placement of t...
 In

the asymmetric smile curtain, there is a
differential elevation of the upper lip during
smile, which gives the illus...
OBLIQUE DIMENSION


The oblique view of the smile shows
characteristics of the smile not obtainable on the
frontal view o...
It is important to visualize the occlusal plane and its
relationship to the lower lip.
In preparation for maxillary surger...
This is best visualized in
the oblique view.

www.indiandentalacademy.com
 The

visualization
of the complete
smile arc afforded
by the oblique
view expands the
definition of the
smile arc to
inc...
SAGITTAL DIMENSION


The 2 characteristics of the smile that are best
visualized in the sagittal dimension are overjet an...


Incisor proclination in the
sagittal dimension can also
have a dramatic effect on
incisor display.
 In simple terms, f...
Effect of retraction of incisors following
extraction of four premolars.
www.indiandentalacademy.com
THE FOURTH DIMENSION: TIME


The growth, maturation, and aging of the perioral
soft tissues have a profound effect on the...


Adolescent patients, or those at the point of
pubertal onset, have experienced the maximum
velocity in the growth of th...


In a direct measurement study of more than 3500
subjects, Dickens et al (World Journal of
Orthodontics, 2002) studied t...
1.

2.
3.
4.

5.

The effects of maturation and aging on the
soft tissues can be summarized as
Lengthening of the resting ...
Influence of extractions on smile
esthetics


The recent criticism concerning the detrimental
effects of premolar extract...
 Documentation of

the adverse effects of
extraction treatment on smiles is scarce.
 Luppanpornlarp and Johnston (Angle
...
Johnson and Smith (AJODO‟95) determined that
smile esthetics, esthetic scores, and visible
dentition during a smile were t...


Kim and Gianelly (Angle Orthod 2003) studied
the dental casts of 30 patients treated with
extraction and 30 patients wi...
 Intercanine width

increased less than one
mm in both groups, and there was no
difference between the two groups.
 When...


The mean esthetic score and the number of teeth
displayed during a smile did not differ between the
groups.
 The resul...


Isiksal, Hazar and Akyalcin (AJODO 2006)
compared smile esthetics among extraction and
nonextraction patients and a con...
Importance of tooth shape in smile
esthetics


Many notions held today on the esthetics of
tooth shape are based on autho...


Other popular methods for selecting tooth
shapes in the past were based on
stereotypes: women should have round, soft,
...


They were tested for incisor shape
preferences while maintaining canine
shape, and for canine shape preferences
while m...
www.indiandentalacademy.com


Restorative dentists preferred round incisors
for the female images. Orthodontists
preferred round and square-round inc...
It would be wise to involve the patient in
treatment planning, whether it involves
incisal-edge recontouring or complete
r...
Principles of cosmetic dentistry in
orthodontics:
 Contemporary orthodontic smile

analysis is
generally defined in terms...
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
Use of laser gingivectomy to achieve
smile esthetics.

www.indiandentalacademy.com
www.indiandentalacademy.com
www.indiandentalacademy.com
Maxillary midline diastema


Sivakumar A and Valiathan A (Kerala Dental
Journal, July 2006) emphasized the need to
correc...


Roots should be allowed to converge together so
that relapse could be compensated.
 Especially in cases of tooth size ...


Contrary to popular belief, a study by Shashua and
Artun (Angle Orthod 1999) could find no
association between relapse ...
Conclusion


Today, well occluding casts and pleasing profiles
can no longer be considered to be adequate
treatment goals...
A

sound knowledge of orthodontic
mechanics and growth changes as well as
the principles of cosmetic dentistry should
hel...


References:
1. Verma N, Valiathan A. An understanding of facial
esthetics and its role in orthodontics. Kerala
Dental J...
6. Zachrisson BU. Esthetic factors involved in
anterior tooth display and the smile: vertical
dimension. J Clin Orthod 199...
10. Morley J, Eubank J. Macroesthetic elements of
smile design. J Am Dent Assoc 2001;132:39-45
11. Rubin LR. The anatomy o...
15. Johnson D, Smith R. Smile esthetics after
orthodontic treatmentwith and without
extraction of four first premolars. Am...
18. Polo M. Botulinum toxin type A in the treatment
of excessive gingival display Am J Orthod
Dentofacial Orthop 2005;127:...
22. Sarver DM. Principles of cosmetic dentistry in
orthodontics: part 1. Shape and proportionality
of anterior teeth. Am J...
26. Sivakumar A, Valiathan A. Maxillary
midline diastema- A closer look. Kerala
Dental Journal 2006; 29(3): 25-26.
27. Rav...
Thank you
For more details please visit
www.indiandentalacademy.com

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Smile esthetics in othodontics. /certified fixed orthodontic courses by Indian dental academy

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Transcript of "Smile esthetics in othodontics. /certified fixed orthodontic courses by Indian dental academy "

  1. 1. Smile esthetics in orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2.  Introduction  Historical aspects  The esthetic paradigm  Records in treatment of the smile  Tooth-lip relationships  The social smile and the enjoyment smile.  Analysis of the smile in 4 dimensions. (Frontal, Sagittal, Oblique, Time-specific.) www.indiandentalacademy.com
  3. 3.  Influence of extractions on smile esthetics  Tooth shape and smile esthetics  Principles of cosmetic dentistry in smile esthetics.  Maxillary midline diastema.  Conclusion www.indiandentalacademy.com
  4. 4. Introduction  The importance of beauty and attractiveness in today’s society has been well established.  Physically attractive people are perceived to be more kind, sensitive, interesting, strong, poised, modest, sociable, outgoing, exciting, and responsive. (Dion et al 1972)  It is also believed that attractive people are more likely to obtain better jobs,have more successful marriages, and experience happier,more fulfilling lives.  These societal biases begin early in life and impact a person’s future for a lifetime. www.indiandentalacademy.com
  5. 5.  Dentofacial attractiveness is particularly important to a person’s psychosocial well being.  People with a normal dental appearance are judged more socially attractive over many personal characteristics than those with malocclusions. (Shaw et al AJO 1985)  Those with poor dental esthetics have been linked to lack of self-confidence and are thought to be disadvantaged in social, educational, and occupational www.indiandentalacademy.com
  6. 6.  During interpersonal interactions, the eyes primarily scan other people’s eyes and mouths, with little time spent on other features. (Miller, 1970)  Thus it is not surprising that the general public considers the smile to rank second only to the eyes when considering features most important to facial esthetics. (Goldstein, 1969)  Tatarunaite et al (AJODO 2005) reported that smiling and youthful facial appearance make women look more attractive www.indiandentalacademy.com
  7. 7.  Esthetics, which is derived from the Greek word for perception, deals with beauty and the beautiful.  It may be divided into two dimensions: objective (admirable) and subjective (enjoyable ) beauty.  Objective beauty implies that the object possesses properties that make it unmistakably praiseworthy.  Subjective beauty is value laden, and is related to the tastes of the person contemplating it. www.indiandentalacademy.com
  8. 8.  Contemporary techniques in orthodontics should lend objective esthetics to the entire orofacial complex involving unity, form, color, function and display of the dentition.  In addition, the creation of subjective beauty according to the orthodontist‟s own preferences may enhance the cosmetic value of treatment given to each patient. www.indiandentalacademy.com
  9. 9. Esthetics in orthodontics has been defined mainly in terms of profile enhancement, but if you ask lay people what an orthodontist does, their answers will usually include something about creating beautiful smiles. www.indiandentalacademy.com
  10. 10. Historical aspects  The study of frontal facial form dates back to the Egyptians, who depicted ideal facial esthetics as the ―golden proportion.‖ This concept has been described extensively in classical art and orthodontic literature. www.indiandentalacademy.com
  11. 11. In the latter part of the 19th century, Norman Kingsley, the leading orthodontist of the era, emphasized the esthetic objectives of orthodontic treatment. In the Kingsley paradigm, the articulation of the teeth was clearly secondary to facial appearances. www.indiandentalacademy.com
  12. 12. Edward Angle‟s emphasis on occlusion led him to teach that optimal facial esthetics always coincided with ideal occlusion and that esthetics could essentially be disregarded because it took care of itself.  Classification schemes were based on static morphologic features, such as molar relationships and the extent of facial divergence.  Also, the early concepts of esthetics revolved largely around the patient’s profile, and it was believed that, once the ―ideal‖ tooth–jaw positions were achieved, then the soft tissues would fall in line.  www.indiandentalacademy.com
  13. 13.  This focus on the profile was because the lateral cephalogram has long been the lynchpin of orthodontic treatment planning.  As a result, orthodontics tended to drift away from clinical examination of the patient and the art of physical diagnosis.  There is little debate about the many advancements that Angle made in orthodontics, most notably his system of classifying malocclusion.  But perhaps more attention should be paid to his inclusion of art in the orthodontic search for quantifying facial beauty. www.indiandentalacademy.com
  14. 14.  Art instruction by Prof Wuerpel was an integral part of the Angle curriculum, but it has gradually disappeared from the modern residency program.  When orthognathic surgery developed in the 1970s and growth modification treatment reappeared for children, the goal was to obtain better occlusion more than better facial proportions.  In the 1980s, the introduction of new esthetic materials in restorative dentistry led to the widespread adoption of “esthetic dentistry.”  At about the same time, it became clearer to all involved that orthognathic surgical goal setting was esthetically www.indiandentalacademy.com driven.
  15. 15. The esthetic paradigm  Although ideal occlusion remained the primary functional goal, it was acknowledged that the esthetic outcome was critical for patient satisfaction.  This has led to the emergence of the esthetic paradigm in orthodontic treatment.  A paradigm can be thought of as “ a set of shared beliefs and assumptions that represent the conceptual foundation for an area of science or clinical practice. www.indiandentalacademy.com
  16. 16.  Today’s ―art of the smile‖ is being driven by the orthodontist’s ability to clinically examine the patient in 3 dimensions and use the latest technology (computer databasing of the clinical examination and digital videography) to document, define, and communicate the treatment strategy to patients and colleagues involved in interdisciplinary care. www.indiandentalacademy.com
  17. 17.  The contemporary orthodontist no longer evaluates patients in terms of only the profile, but also frontally and vertically, to complete the 3 spatial dimensions, and statically and dynamically.  Also, the orthodontist must now add a fourth dimension: Time www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19.  Orthodontists are the first in line in a decision-making process that ultimately affects a patient’s appearance for the rest of his or her life.  The orthodontist must understand not only dentoskeletal growth and development, but also soft tissue growth, maturation, and aging. www.indiandentalacademy.com
  20. 20.  The orthodontist must work with 2 dynamics. A. Soft tissue repose and animation assessed at the patient’s examination including how the lips animate on smile, gingival display, crown length, and other attributes of the smile. B. Facial change throughout a patient’s lifetime: the impact of skeletal and soft tissue maturational and aging characteristics, which are well documented. www.indiandentalacademy.com
  21. 21. Records in the treatment of the smile 3 categories of orthodontic records  Static records (Photographs)  Dynamic records (Video)  Direct biometric measurements www.indiandentalacademy.com
  22. 22. Photographs:  In addition to the standard frontal at rest, frontal smile and profile at rest images, Sarver and Ackerman (AJO DO 2003) recommend 4 additional views:  Profile smile  Oblique smile  Frontal smile closeup  Oblique smile closeup www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24.  Dynamic recording is accomplished with digital videography  Digital video and computer technology enables the clinician to record anterior tooth display during speech and smiling at the equivalent of 30 frames per second.  5 seconds of video for each patient may be taken, yielding 150 frames for comparison.  One segment of video is taken in the frontal dimension and one from the oblique view. www.indiandentalacademy.com
  25. 25. www.indiandentalacademy.com
  26. 26. Direct measurement as a biometric tool  Quantification of resting and dynamic liptooth relationships is critical to smile visualization.  Direct measurement also has application in research efforts relative to time related changes and the repeatability of the social smile. www.indiandentalacademy.com
  27. 27. Tooth-lip relationships Systematic measurement of resting tooth–lip relationships virtually leads the clinician to a quantified treatment plan. The following frontal measurements should be performed :  Philtrum and commissure height,  Interlabial gap,  Incisor show at rest and smile,  Crown height, Gingival display,  Smile arc. www.indiandentalacademy.com
  28. 28. Philtrum height is measured in millimeters from subspinale (the base of the nose at the midline) to the most inferior portion of the upper lip on the vermilion tip beneath the philtral columns. www.indiandentalacademy.com
  29. 29.  Commissure height is measured from a line constructed from the alar bases through subspinale, and then from the commissures perpendicular to this line.  Interlabial gap is the distance in millimeters between the upper and lower lips when lip incompetence is www.indiandentalacademy.com present.
  30. 30.  The absolute linear measurement of philtrum height is not particularly important, but its relationship to the upper incisor and the commissures of the mouth is significant.  In the adolescent, the philtrum height is often shorter than the commissure height, and the difference can be explained in the differential in lip growth with maturation. www.indiandentalacademy.com
  31. 31. A short philtrum in adults results in an unesthetic maxillary lip line which makes resting posture resemble a frown. www.indiandentalacademy.com
  32. 32. Incisor show at Rest and Smile  The amount of maxillary incisor show at rest is a critical parameter esthetically, because it is an inevitable characteristic of aging  As a general guideline, in adolescents 3-4 mm of the maxillary incisor should be displayed at rest, and the entire clinical crown with some gingiva should be seen on smiling.  Generally, males show less upper incisors and more of lower incisors, while females show more of upper incisors and less of lower incisors. www.indiandentalacademy.com
  33. 33.  Peck et al (AJODO 1992) showed that the normal display of maxillary incisors with relaxed lips at 15 years age is 4.7 + 2 mm for boys and 5.3 + 1.8 mm for girls. This sexual dimorphism is evident at all ages.  Also, Whites show more of upper incisor but less lower incisor at rest than do Asians or Africans. www.indiandentalacademy.com
  34. 34.  Excessive tooth display is judged better at rest than on smile, because lip elevation on smiling is quite variable.  If exposure at rest is normal, even if a considerable amount of gingival display occurs on smiling, this should be considered normal for that individual. www.indiandentalacademy.com
  35. 35. A gummy smile can be esthetic ! www.indiandentalacademy.com
  36. 36.  In 1992, Peck et al described how orthodontists and surgeons are conditioned to see high gingival smile lines as undesirable and concluded that the gingival smile line is not influenced by upper lip length, incisor crown height, mandibular plane angle, or palatal plane angle. www.indiandentalacademy.com
  37. 37.  They noted that the biological mechanisms of the gingival smile line are influenced by anterior vertical maxillary excess, greater muscular capacity to raise the lip, and supplemental factors, such as excessive overjet and overbite.  They also noted that the location of the gingival smile line largely depended on the subject’s sex. On average, the smile line in women is 1.5 mm higher than in men. www.indiandentalacademy.com
  38. 38.  Dong et al (Int J Prosthod 1999) compared the age changes in maxillary and mandibular incisor display at rest and when smiling and found that aging (from 30 years to 60 years) was associated with a steady decrease in maxillary incisor display and a concomitant increase in mandibular incisor display.  This is associated with sagging of the perioral soft tissue partly due to the natural flattening, stretching and decreasing elasticity of the skin with age. www.indiandentalacademy.com
  39. 39. www.indiandentalacademy.com
  40. 40.  The importance of proper planning for vertical incisal positioning in orthodontics and orthognathic surgery cannot be overemphasized.  It may make all the difference between a youthful and an elderly smile at end of treatment. www.indiandentalacademy.com
  41. 41. Crown height  The percentage of incisor display, when combined with crown height, helps the clinician decide how much tooth movement is required to improve the smile index.  Crown height is the vertical height of the maxillary central incisors; in adults, crown height is normally between 9 and 12 mm, with an average of 10.6 mm in men and 9.6 mm in women.  The age of the patient is a factor in crown height because of the rate of apical migration in the adolescent. www.indiandentalacademy.com
  42. 42. The Smile Arc  The smile arc from the frontal view is the relationship of the curvature of the incisal edges of the maxillary incisors and canines to the curvature of the lower lip in the posed social smile.  In an ideal smile arc, the curvature of the maxillary incisal edge is parallel to the curvature of the lower lip upon smile; the term consonant describes this parallel relationship.  In a nonconsonant or flat smile, the maxillary incisal curvature is flatter than the curvature of the lower lip on smile. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com
  44. 44.  Tjan et al (J Prosthet Dent 1984) in a survey of young Los Angeles adults, found that a great majority (85%) had a maxillary incisal smile curve parallel to the inner contour of the lower lip, 14% showed a straight rather than a curved line, and only 1% had a reverse smile curve. www.indiandentalacademy.com
  45. 45. The Social Smile and the Enjoyment Smile.  The social smile is a voluntary smile a person uses in social settings or when posing for a photograph. When you are introduced to someone, your smile indicates that you are friendly and “pleased to meet” that person.  The enjoyment smile (or Duchenne smile) is an involuntary smile and represents the emotion you are experiencing at that moment. It is natural in that it represents authentic emotion and dynamic in that it bursts forward and but is not sustained. www.indiandentalacademy.com
  46. 46. www.indiandentalacademy.com
  47. 47.  What differenciates the social smile from the enjoyment smile is not the activity of the orbicularis oris musculature, but instead the participation of the orbicularis oculi.  In the enjoyment smile there is a crinkling around the eyes that cannot be duplicated with a social smile.  According to both Darwin and Duchenne, we “smile with our eyes.” www.indiandentalacademy.com
  48. 48.    1. 2. 3. Tarantili, Halozonetis and Spyropoulos (AJODO 2005) recorded and analyzed spontaneous smiles in fifteen children, average age of 10.5 years, using a hidden camera while they watched a funny cartoon. The spontaneous smile was found to develop in a staged fashion. Three stages were identified: An initial attack period from relaxed neutral position to full smile. (500 milliseconds) A sustaining period (Variable time period) A fadeout or decay period back to relaxed posture. www.indiandentalacademy.com
  49. 49.  The smiles were accompanied by display of teeth and mouth opening, though not consistently.  On average, facial measurements showed that the upper lip elevated by 28% and the mouth increased in width by 27%, while the corners of the mouth moved laterally and superiorly at an angle of approximately 45 degrees. www.indiandentalacademy.com
  50. 50.  The smile extended over the whole face including wrinkling around the eyes and contraction of the orbicularis oculi muscles, confirming that the smile was genuine.  The frequency and extent of smiling were enhanced in the presence of other children, showing that smiling is a social activity that people like to share.  This study emphasizes the point that conventional photographic records of the smile might involve errors related to capturing a time-evolving event at a single instant.  Video recordings may provide more comprehensive information for assessment of facial esthetics. www.indiandentalacademy.com
  51. 51.  In treating the smile, the social smile generally represents a repeatable smile. Sarver and Ackerman (AJODO 2003) chose the social smile as the representation in order to analyze the smile in 4 dimensions: frontal, oblique, sagittal, and time-specific. www.indiandentalacademy.com
  52. 52. FRONTAL DIMENSION  To visualize and quantify the frontal smile, Ackerman and Ackerman (1998), developed a ratio, called the smile index, that describes the area framed by the vermilion borders of the lips during the social smile.  The smile index is determined by dividing the intercommissure width by the interlabial gap during smile. This ratio is helpful for comparing smiles among different patients or across time in 1 patient. www.indiandentalacademy.com
  53. 53. This patient has small smile index value with substantial incisor display on smile. www.indiandentalacademy.com
  54. 54.  Frontally, we can visualize and quantify 2 major dimensions of the smile: vertical and transverse characteristics.  The vertical characteristics of the smile are broadly categorized into 2 main features: those pertaining to incisor display and those pertaining to gingival display.  If, for example, the patient shows less than 75% of the central incisor crowns at smile, tooth display is considered inadequate. (Morley and Eubank, JADA 2001.) www.indiandentalacademy.com
  55. 55. Inadequate incisor display can be due to:  Vertical maxillary deficiency  Limited smile area (a large smile index),  Short clinical crown height. Short clinical crown height could be due to  Lack of tooth eruption (treated with observation),  Gingival encroachment (treated with cosmetic periodontics),  Short incisors secondary to attrition (treated with cosmetic dentistry). www.indiandentalacademy.com
  56. 56.  Other vertical smile characteristics are the relationships between the incisal edges of the maxillary incisors and the lower lip, and between the gingival margins of the maxillary incisors and the upper lip.  The gingival margins of the canines should be coincident with the upper lip and the lateral incisors positioned slightly inferior to the adjacent teeth.  It is generally accepted that the gingival margins should be coincident with the upper lip in the social smile. However, this is very much a function of age, because children show more tooth at rest and have more gingival display on smile than do adults. www.indiandentalacademy.com
  57. 57.  1. 2. 3. Tjan and Miller (1984) described three types of smiles acording to lip coverage of maxillary incisors in full smile: The average smile, that reveals 75-100% of the upper incisors (most frequent). The low smile which displays < 75% of the maxillary incisors (found in 20% of population.) High/ gummy smile, revealing the complete cervicoincisal length of the upper incisors and a contiguous band of gingiva.(10% of the population) www.indiandentalacademy.com
  58. 58. Clinical implications for Deep Overbite correction Average and low smile types  Correction of deep anterior overbite can be made with various combinations of incisor intrusion and molar extrusion.  In the past, active intrusion of maxillary incisors with intrusion arches, utility arches and other approaches has been considered a cornerstone of deep bite correction.  However, over-intrusion of upper incisors tends to hide them behind the upper lip when the patient is speaking.  With increasing age of the patient and drooping of upper lip, this would predictably worsen over time. www.indiandentalacademy.com
  59. 59.  The optimal vertical reference position for the maxillary incisal edge in orthodontic treatment planning is with relaxed lips.  For young adults (20-30 years): At least 3 mm of maxillary incisor show.  For adults 30-40 years: About 1.5 mm of maxillary incisor show.  Adults 40-50 years: About 1mm .  In patients 50-60 years: No maxillary incisor show at rest. www.indiandentalacademy.com
  60. 60. Prior to treatment, each patient‟s tooth display should be carefully analyzed at rest and speech, before deciding whether maxillary intrusion mechanics are indicated.  From the esthetic point of view, the best strategy in the majority of cases of deep overbite is active intrusion of mandibular incisors.  This is especially when the curve of Spee is marked, and the six anterior teeth are above the functional occlusal plane.  Achieved using overlay base arches or segmented arch mechanics.  www.indiandentalacademy.com
  61. 61. Reduced anterior overbite and high erupting canines  Use of a continuous leveling wire may overintrude the incisors into functionally and esthetically unacceptable positions. This should be avoided.  In such cases the first molars should be connected with a TPA to yield reliable posterior anchorage, and a cantilever wire from the extra tube used to bring down the canines. www.indiandentalacademy.com
  62. 62. Treatment of gummy smiles  The biologic mechanism of gummy smiles appears to involve anterior vertical excess, increased muscular ability to raise the upper lip on smiling, excessive interlabial gap at rest and excess overbite and overjet.  Different treatment strategies are needed for patients with high smile line, involving various combinations of orthodontic, periodontal and surgical therapy.  Both the incisor show at rest and gingival show on smiling should be considered. www.indiandentalacademy.com
  63. 63.  If maxillary incisor show at rest is optimal, active upper incisor intrusion should not be initiated. Instead surgical crown lengthening with removal of crestal alveolar bone should be made.  Especially desirable in case of excess marginal gingiva and short clinical crowns. www.indiandentalacademy.com
  64. 64. Treatment of most severe gummy smiles may require maxillary superior repositioning surgery (Le Fort I osteotomy) along with reduction of the associated vertical maxillary excess. www.indiandentalacademy.com
  65. 65. Gummy smile treated with combination of maxillary impaction surgery and crown lengthening www.indiandentalacademy.com
  66. 66.  Gummy smiles can also be treated using plastic surgery to correct the hyperfunction of upper lip muscles, especially by resection of the levator labii superioris.  However Ellenbogen (Plastic Reconstr Surg 1984) reported that resection of the levator labii superioris is short-lived, with the gummy smile returning within 6 months.  He advocated placing a spacer, either nasal cartilage or prosthetic material, between the stumps to prevent the muscles from being reunited and again hyperelevating the lip. www.indiandentalacademy.com
  67. 67. Use of Botox for treatment of gummy smiles.  Botulinum toxin has been under clinical investigation since the late 1970s for the treatment of several conditions associated with excessive muscle contraction or pain.  Botulinum toxin is produced by the anaerobic bacterium Clostridium Botulinum.  Type A (BTX-A), marketed as Botox, is the most potent and the most commonly used clinically. www.indiandentalacademy.com
  68. 68.  BTX-A weakens skeletal muscles by cleaving the synaptosome-associated protein SNAP25, thus blocking the release of acetylcholine from the motor neuron and enabling the repolarization of the postsynaptic terminal.  As a result, the muscular contraction is blocked. The production of acetylcholine is not affected by this blockade of the neuromuscular transmission. www.indiandentalacademy.com
  69. 69.  Polo M (AJODO 2005) described a nonsurgical alternative for reducing excessive gingival display caused by muscle hyperfunction, using Botox.  Five subjects with excessive gingival display due to hyperfunctional upper lip elevator muscles were treated with BTX-A injections in the levator muscles.  This treatment modality was effective, producing esthetically acceptable smiles in these patients.  The improvements lasted 3 to 6 months. www.indiandentalacademy.com
  70. 70. www.indiandentalacademy.com
  71. 71. www.indiandentalacademy.com
  72. 72. Injection with BTX-A provides effective, minimally invasive, temporary improvement of gummy smiles for patients with hyperfunctional upper lip elevator muscles. www.indiandentalacademy.com
  73. 73. Flattening of the Smile Arc  Undesirable flattening of the smile arc is greatly underestimated in orthodontics.  Hulsey (AJO 1970) assessed standardized photographs of 40 subjects, 20 treated orthodontically and 20 considered to have normal occlusion. He noted that the curvature of the incisal edges of the maxillary anterior teeth was flatter in those who were treated orthodontically.  Ackerman et al (1998) reported that the smile arc of as many as 32% of their patients was flattened during treatment. www.indiandentalacademy.com
  74. 74.  Normal orthodontic alignment of the maxillary and mandibular arches may result in a loss of the curvature of the maxillary incisors relative to the lower lip curvature.  It is important to assess and visualize the incisor-smile arc relationships and place brackets so as to extrude the maxillary incisors in flat smiles and to maintain the smile arc where it is appropriate. www.indiandentalacademy.com
  75. 75.  If all patients routinely have their maxillary central incisors placed 4.5 mm above the incisal edge, their lateral incisors at 4 mm, and their canines at 5 mm, without the clinician taking into account the relationship of the incisal edges to the lower lip curvature in each individual case, the positioning may or may not fit the esthetic criteria required. www.indiandentalacademy.com
  76. 76.  Bracket placement, with emphasis on the goal of attaining canine guidance may create relative intrusion of the maxillary incisors while extruding the maxillary canines.  This could lead to non-consonant smile. www.indiandentalacademy.com
  77. 77. www.indiandentalacademy.com
  78. 78.  In patients in whom excessive gingival display on smile is noted, and for whom one of the treatment objectives is to reduce the gumminess of the smile, maxillary incisor intrusion may improve the gingival display on smile.  However, if the smile arc relationship has not been noted and evaluated, unwanted flattening of the smile arc may result.  Maxillary intrusion arches or maxillary archwires with accentuated curve could result in a flattening of the smile arc. www.indiandentalacademy.com
  79. 79. Midline considerations  When viewing dentitions, many clinicians use the maxillary central incisors as their esthetic baseline  However, considering the importance of the facial midline, there remains confusion regarding techniques for reliably locating it.  Careful photographic analysis of patients’ faces shows that prominent facial anatomy— including the eyes, nose and chin—can be deceptive in locating the midline. www.indiandentalacademy.com
  80. 80. A practical approach to locating the facial midline references two anatomical landmarks. The first is a point between the brows known as the nasion  The second is the base of the philtrum, also referred to as the cupid’s bow in the center of the upper lip.  A line drawn between these landmarks not only locates the position of the facial midline but also determines the direction of the midline . www.indiandentalacademy.com
  81. 81. www.indiandentalacademy.com
  82. 82.  Whenever possible, the midline between the maxillary central incisors should be coincidental with the facial midline.  In cases in which this is not possible, the midline between the central incisors should be parallel to the facial midline.  If the visual junction of maxillary central incisors is at an angle to the facial midline, it is referred to as a canted midline.  Canting is a major design flaw in any natural or restored dentition. www.indiandentalacademy.com
  83. 83.  According to Kokich, as long as the maxillary midline deviation is parallel to the facial midline, even a 4mm maxillary midline deviation was not noticed by dentists and laypeople.  However, even a 2 mm deviation in incisor angulation was noticeably unattractive. www.indiandentalacademy.com
  84. 84. Transverse characteristics  The transverse characteristics of the smile in the frontal dimension are  Arch form,  Labiolingual crown-inclinations of teeth,  Buccal corridor and  Transverse cant of the maxillary occlusal plane. www.indiandentalacademy.com
  85. 85.  Arch form plays a pivotal role in the transverse dimension of the smile. Recently, much attention has been focused on the use of broad, square arch forms in orthodontic treatment.  When the arch form is narrow or collapsed, the smile may also appear narrow and therefore present inadequate transverse smile characteristics. www.indiandentalacademy.com
  86. 86.  An important consideration in widening a narrow arch form, particularly in adults, is the axial inclination of the buccal segments.  Patients whose posterior teeth are already flared laterally are not good candidates for dental expansion. Patients with upright premolars and molars have more capacity for transverse expansion;  This is true in adolescents, but it is particularly important in adults because sutural expansion is less likely. www.indiandentalacademy.com
  87. 87. Orthodontic expansion and widening of a collapsed arch form can dramatically improve the smile by decreasing the size of the buccal corridors and improving the transverse smile dimension www.indiandentalacademy.com
  88. 88. Labiolingual crown inclinations:  Generally 90% of people show the 1st or 2nd premolar as the last tooth when smiling.  To create the illusion of smile fullness, the last premolar should be positioned relatively upright.  Torque prescriptions for most preadjusted appliance systems tend to create too much lingual crown inclination, which may not be optimal from the esthetic perspective.  Crown inclination symmetry of contralateral teeth contribute to to an optimally esthetic appearance., and necessary archwire correction bends should be made to achieve this. www.indiandentalacademy.com
  89. 89. www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. Buccal corridors  The transverse smile dimension is also related to the lateral projection of the premolars and the molars into the buccal corridors.  The buccal corridor may be defined as “ The distance from the posterior teeth to the corners of the lips ”(Frush and Fisher, 1958)  Frush and Fisher considered the buccal corridor to be a normal feature of a dentition that prevents the “Sixty tooth Smile” that is often characteristic of a denture. www.indiandentalacademy.com
  92. 92.  They stated that the size and shape of the buccal corridors were not important, as long as the buccal corridors were noticed.  The wider the arch form in the premolar area, the greater the portion of the buccal corridor that is filled. www.indiandentalacademy.com
  93. 93.  Only a few studies have determined the esthetic value of the buccal corridor space.  In 1995, Johnson and Smith found that extraction of teeth during orthodontic treatment had no effect on the buccal corridors.  Similar findings were reported by Gianelly (AJODO 2003) who found no differences in arch width in extraction and nonextraction patients.  Hulsey (AJO 1970) also reported that there was no relation between buccal corridors and smile scores.  However, Hulsey measured the buccal corridor from the canine to the corner of the mouth. www.indiandentalacademy.com
  94. 94. In adolescents, it is often desirable to increase arch width with rapid maxillary expansion to create space for non-extraction treatment. www.indiandentalacademy.com
  95. 95.  Arch expansion might fill out the transverse dimension of the smile, but 2 undesirable side effects could result, and careful observation is needed to avoid these, if possible. 1. The buccal corridor can be obliterated, resulting in a denture-like smile. www.indiandentalacademy.com
  96. 96. 2. When the anterior sweep of the maxillary arch is broadened, the smile arc may be flattened  This is particularly important today because of the trend toward broader arch forms. www.indiandentalacademy.com
  97. 97.  Although it may not be possible to avoid these undesirable aspects of expansion, the clinician must make a judgment in concert with the patient as to what tradeoffs are acceptable in the pursuit of the ideal smile. www.indiandentalacademy.com
  98. 98.  According to Moore et al (AJODO Feb 2005) the esthetic values of today may differ from those of 50 years ago.  People now keep their teeth longer, and there has been a shift away from complete denture prosthodontics.  Thus, a full smile might no longer be perceived as a denture smile. www.indiandentalacademy.com
  99. 99.  The same authors carried out a study in which color slides of 10 smiling subjects were digitally altered to produce narrow, medium narrow, medium, medium broad and broad smiles. www.indiandentalacademy.com
  100. 100. www.indiandentalacademy.com
  101. 101.  Analysis showed that lay persons considered broader smiles to be more attractive as compared to narrow smiles.  They concluded that having minimal buccal corridors is a preferred esthetic feature for both men and women, and large buccal corridors should be included in the problem list during diagnosis and treatment planning www.indiandentalacademy.com
  102. 102.  In another study by Roden-Johnson et al (AJODO March 2005), smiling photographs of 20 women treated by 2 orthodontists were collected: 1 group had narrow tapered or tapered arch forms, and the other had normal to broad arch forms.Photographs of 10 untreated women served as a control sample.  The photographs with Buccal Corridor Space were altered to eliminate the dark triangular areas, and those without it were altered by the addition of dark triangular areas at the lateral aspects of the smile.  Three groups of raters (dentists, orthodontists, and laypeople) used a visual analogue scale to rate the www.indiandentalacademy.com
  103. 103.  There was no significant difference in smile scores related to BCS for all samples and for all viewers.  Dentists rated broader arch forms as more esthetic than untreated arch forms. Orthodontists rated broader arch forms as more esthetic than narrow tapered arch forms and untreated arch forms.  Lay people showed no preference of arch form.  This study demonstrated that the presence of BCS does not influence smile esthetics.  However, there are differences in how dentists, orthodontists, and laypeople www.indiandentalacademy.com
  104. 104. Transverse cant of the maxillary occlusal plane.  Transverse cant can be due to differential eruption and placement of the anterior teeth or skeletal asymmetry of the mandible resulting in a compensatory cant of the maxilla.  Only frontal smile visualization permits the orthodontist to visualize any tooth-related or skeletal asymmetry transversely.  Smile asymmetry may also be due to soft tissue considerations, such as an asymmetric smile curtain. www.indiandentalacademy.com
  105. 105.  In the asymmetric smile curtain, there is a differential elevation of the upper lip during smile, which gives the illusion of a transverse cant to the maxilla.  It is poorly documented in static photographic images and is documented best in digital video clips. www.indiandentalacademy.com
  106. 106. OBLIQUE DIMENSION  The oblique view of the smile shows characteristics of the smile not obtainable on the frontal view or through any cephalometric analysis.  The palatal plane can be canted anteroposteriorly in a number of orientations.  In the most desirable orientation, the occlusal plane is consonant with the curvature of the lower lip on smile.  Deviations from this orientation include a downward cant of the posterior maxilla, upward cant of the anterior maxilla, or variations of both. www.indiandentalacademy.com
  107. 107. It is important to visualize the occlusal plane and its relationship to the lower lip. In preparation for maxillary surgery to close an anterior open bite, whether the posterior maxilla should be impacted or the anterior maxilla should come down depends on the amount of incisor show at rest and on smile and the smile arc relationship. www.indiandentalacademy.com
  108. 108. This is best visualized in the oblique view. www.indiandentalacademy.com
  109. 109.  The visualization of the complete smile arc afforded by the oblique view expands the definition of the smile arc to include the molars and the premolars www.indiandentalacademy.com
  110. 110. SAGITTAL DIMENSION  The 2 characteristics of the smile that are best visualized in the sagittal dimension are overjet and incisor angulation.  Excessive positive overjet is one of the dental traits most recognizable to the lay person.  In many Class II patterns, the smile is esthetic frontally, but the problem is obvious when observed from the side.  In Class III patterns too, the frontal smile looks esthetic but the oblique or sagittal view shows the underlying skeletal pattern and dental compensation. www.indiandentalacademy.com
  111. 111.  Incisor proclination in the sagittal dimension can also have a dramatic effect on incisor display.  In simple terms, flared maxillary incisors tend to reduce incisor display, and upright maxillary incisors tend to increase it www.indiandentalacademy.com
  112. 112. Effect of retraction of incisors following extraction of four premolars. www.indiandentalacademy.com
  113. 113. THE FOURTH DIMENSION: TIME  The growth, maturation, and aging of the perioral soft tissues have a profound effect on the appearance of both the resting and smiling presentations.  In preadolescent patients, the facial soft tissues are still in a growth phase, and treatment decisions pertaining to the relative facial divergence at profile and frontal facial soft tissue topography must take this into account. www.indiandentalacademy.com
  114. 114.  Adolescent patients, or those at the point of pubertal onset, have experienced the maximum velocity in the growth of the skeletal subunits and have roughly achieved their facial soft tissue “look.”  In adults, nuances in the aging of perioral and facial soft tissues become increasingly important.It is known from orthodontic cephalometric research that, on average, profiles flatten over time. www.indiandentalacademy.com
  115. 115.  In a direct measurement study of more than 3500 subjects, Dickens et al (World Journal of Orthodontics, 2002) studied the changes in philtrum height and commissure height in patients from age 6 years to their 40s and the relationship to the smile.  These data demonstrate the lengthening of the philtrum and commissure, with the rate of philtrum lengthening greater than that of the commissures.  This would explain the flattening of the “M” characteristics of the vermilion border of the upper lip in the youthful lip. www.indiandentalacademy.com
  116. 116. 1. 2. 3. 4. 5. The effects of maturation and aging on the soft tissues can be summarized as Lengthening of the resting philtrum and commissure heights. Decrease in turgor (or tissue “fleshiness”) Decrease in incisor display at rest, Decrease in incisor display during smile Decrease in gingival display during smile. www.indiandentalacademy.com
  117. 117. Influence of extractions on smile esthetics  The recent criticism concerning the detrimental effects of premolar extraction therapy on smile esthetics has added another dimension to the 100year-old extraction vs nonextraction debate.  Presumably, extraction treatment results in narrower dental arches which are associated with a less esthetic smile because the dentition is less full during a smile.  In addition, this arch width reduction creates unaesthetic black triangles at the corners of the mouth and „negative‟ spaces lateral to the buccal segments. www.indiandentalacademy.com
  118. 118.  Documentation of the adverse effects of extraction treatment on smiles is scarce.  Luppanpornlarp and Johnston (Angle Orthod 1993) found that in comparable groups of patients treated with and without extractions, the post-treatment intercanine widths of the maxillary and mandibular arches were the same in both groups. www.indiandentalacademy.com
  119. 119. Johnson and Smith (AJODO‟95) determined that smile esthetics, esthetic scores, and visible dentition during a smile were the same in both extraction and nonextraction patients.  Also, arch width, at least in the intercanine zone, is not necessarily narrower after extraction treatment when compared with nonextraction treatment.  www.indiandentalacademy.com
  120. 120.  Kim and Gianelly (Angle Orthod 2003) studied the dental casts of 30 patients treated with extraction and 30 patients without extraction of four first premolars, (all randomly selected to) determine changes in arch width as a result of treatment.  Standardized frontal photographs of the face taken during smiling of 12 extraction- and 12 nonextraction treated subjects were evaluated by fifty laypersons who judged the esthetics of the smiles. www.indiandentalacademy.com
  121. 121.  Intercanine width increased less than one mm in both groups, and there was no difference between the two groups.  When arch widths of both groups were measured from the most labial surfaces of the teeth at a constant depth, the average arch width of both arches was significantly wider in the extraction sample www.indiandentalacademy.com
  122. 122.  The mean esthetic score and the number of teeth displayed during a smile did not differ between the groups.  The results of this study indicate that constricted arch widths are not a usual outcome of extraction treatment and that neither extraction nor nonextraction treatment has a preferential effect on smile esthetics. www.indiandentalacademy.com
  123. 123.  Isiksal, Hazar and Akyalcin (AJODO 2006) compared smile esthetics among extraction and nonextraction patients and a control group, as judged by orthodontists, plastic surgeons, artists, general dentists, dental professionals, and parents.  The mean esthetic scores for the extraction, nonextraction, and control groups were 3.15, 3.12, and 3.26, on a scale of 5, respectively. (no significant difference )  Visible dentition width relative to the smile width ratio and intercanine distance relative to smile width ratio were significantly different among the groups, with extraction patients showing a slightly wider dental arch relative www.indiandentalacademy.com to the soft tissue.
  124. 124. Importance of tooth shape in smile esthetics  Many notions held today on the esthetics of tooth shape are based on authoritative writings aimed at guiding denture tooth selection.  For example, Williams suggested that tooth shape should be determined by facial form.  However, selecting tooth shape on the basis of facial form has not been supported by the literature. In fact,several studies have found no correlation between facial outline and actual or preferred tooth shape. www.indiandentalacademy.com
  125. 125.  Other popular methods for selecting tooth shapes in the past were based on stereotypes: women should have round, soft, and delicate teeth (tapering/ovoid); men should have square, angular teeth.  Anderson et al (AJODO 2005) conducted a study to evaluate the contributions of tooth shape to the esthetic smile. Three groups of judges were recruited: restorative dentists, laypeople, and orthodontists  The judges each evaluated 18 color photographs of smiles portrayed in either a male or female booklet. www.indiandentalacademy.com
  126. 126.  They were tested for incisor shape preferences while maintaining canine shape, and for canine shape preferences while maintaining incisor shape.  Three shapes based on the incisal line angles of the central and lateral incisors: square, square-round, and round.  Three canine shapes were also compared: pointed, round, and flat. www.indiandentalacademy.com
  127. 127. www.indiandentalacademy.com
  128. 128.  Restorative dentists preferred round incisors for the female images. Orthodontists preferred round and square-round incisors for the female images. Laypeople did not express a preference in female incisor shape.  All 3 groups preferred square-round incisors for the male images.  Canine shape played a less important role than incisor shape in the esthetics of the anterior dentition.  Lay people tended to be less critical than dental professionals. Restorative dentists tended to be more critical than both laypeople and orthodontists. www.indiandentalacademy.com
  129. 129. It would be wise to involve the patient in treatment planning, whether it involves incisal-edge recontouring or complete restoration of the anterior dentition. www.indiandentalacademy.com
  130. 130. Principles of cosmetic dentistry in orthodontics:  Contemporary orthodontic smile analysis is generally defined in terms of (1) vertical placement of the anterior teeth to the upper lip at rest and on smile (2) transverse smile dimension (3) smile arc characteristics, and (4) the vertical relationship of gingival margins to each other. www.indiandentalacademy.com
  131. 131. www.indiandentalacademy.com
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  142. 142. Use of laser gingivectomy to achieve smile esthetics. www.indiandentalacademy.com
  143. 143. www.indiandentalacademy.com
  144. 144. www.indiandentalacademy.com
  145. 145. Maxillary midline diastema  Sivakumar A and Valiathan A (Kerala Dental Journal, July 2006) emphasized the need to correctly diagnose the underlying etiology of midline diastema, with the help of medical and dental history and radiographic examination to rule out a supernumerary tooth.  Such conditions can sometimes be treated with removable appliances such as finger springs, split labial bow, but better control can be achieved using fixed appliances with artistic positioning bends in the archwire. www.indiandentalacademy.com
  146. 146.  Roots should be allowed to converge together so that relapse could be compensated.  Especially in cases of tooth size arch length discrepancy, it is preferred to carry out veneer bonding to close the space.  In case of very large diastemas, a combination of orthodontic tooth movement and veneering is preferred. www.indiandentalacademy.com
  147. 147.  Contrary to popular belief, a study by Shashua and Artun (Angle Orthod 1999) could find no association between relapse and the presence of an abnormal frenum or an osseous intermaxillary cleft.  Fremitus was the only parameter at followup associated with space reopening.  Retention is the hardest part of treating a midline diastema orthodontically, and invariably requires fixed permanent retention with multistranded stainless steel wires bonded to the lingual surface of the incisors with composite. www.indiandentalacademy.com
  148. 148. Conclusion  Today, well occluding casts and pleasing profiles can no longer be considered to be adequate treatment goals for the orthodontist.  Since most people interact with each other facing each other directly or obliquely, the smile of the patient should be given adequate importance in treatment planning.  In order to correctly diagnose and treat problems associated with the smile, meticulous clinical observation and record taking in the form of photos and videos is warranted, in various dimensions. www.indiandentalacademy.com
  149. 149. A sound knowledge of orthodontic mechanics and growth changes as well as the principles of cosmetic dentistry should help the orthodontist to truly live up to the epithet of “Smile Architect”. www.indiandentalacademy.com
  150. 150.  References: 1. Verma N, Valiathan A. An understanding of facial esthetics and its role in orthodontics. Kerala Dental Journal 2006; 29(3): 27-30. 2. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod 1970;57:132-44. 3. Mackley RJ. An evaluation of smiles before and after orthodontic treatment. Angle Orthod 1993;63:183-90. 4. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91-100. 5. Sabri R. The eight components of a balanced smile. Journal of Clinical Orthodontics. 2005; 39: 3: 155-167 www.indiandentalacademy.com
  151. 151. 6. Zachrisson BU. Esthetic factors involved in anterior tooth display and the smile: vertical dimension. J Clin Orthod 1998; 32:432-5 7. Ackerman MB, Ackerman J. Smile analysis and design in the digital era. J Clin Orthod 2002;36:221-36. 8. Sarver DM, Ackerman JL. Orthodontics about face: the reemergence of the esthetic paradigm. Am J Orthod Dentofacial Orthop 2000;117:5756. 9. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop 2001;120: 98-111. www.indiandentalacademy.com
  152. 152. 10. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc 2001;132:39-45 11. Rubin LR. The anatomy of a smile: its importance in the treatment of facial paralysis. Plast Reconstr Surg 1974;53:384-7. 12. Sarver D, Ackerman M. Dynamic smile visualization and quantification: part 2. Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop 2003;124:116-27. 13. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51:24-8. 14. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958;8:558-81. www.indiandentalacademy.com
  153. 153. 15. Johnson D, Smith R. Smile esthetics after orthodontic treatmentwith and without extraction of four first premolars. Am J Orthod Dentofacial Orthod 1995;108:162 16. Moore T, Southard K, Casko J, Qian F, and Southard T. Buccal corridors and smile esthetics. Am J Orthod Dentofacial Orthod 2005;127:208-13 17. Sarver D, Ackerman M. Dynamic smile visualization and quantification: Part 1. Evolution of the concept and dynamic records for smile capture (Am J Orthod Dentofacial Orthop 2003;124:4-12) www.indiandentalacademy.com
  154. 154. 18. Polo M. Botulinum toxin type A in the treatment of excessive gingival display Am J Orthod Dentofacial Orthop 2005;127:214-18. 19. Roden-Johnson D, Gallerano R, English J. The effects of buccal corridor spaces and arch form on smile esthetics . Am J Orthod Dentofacial Orthop 2005;127:343-50 20. Kim E, Gianelly A. Extraction vs Nonextraction: Arch Widths and Smile Esthetics. Angle Orthod 2003;73:354–358. 21. Luppanappornlarp S, Johnston LE Jr. The effects of premolar extraction: a long term comparison of outcomes in „„clear-cut‟‟ extraction and non extraction Class II patients. Angle Orthod. 1993; 64:257–272. www.indiandentalacademy.com
  155. 155. 22. Sarver DM. Principles of cosmetic dentistry in orthodontics: part 1. Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop 2004;126:749-53. 23. Sarver DM. Principles of cosmetic dentistry in orthodontics: part 2. Soft tissue laser technology and cosmetic gingival contouring. Am J Orthod Dentofacial Orthop 2005;127:85–90 24. Tarantili V,a Halazonetis D, Spyropoulos M. The spontaneous smile in dynamic motion. Am J Orthod Dentofacial Orthop 2005;128:8-15 25. Anderson K, Behrents R.G, McKinney T, Buschang P Tooth shape preferences in an esthetic smile. Am J Orthod Dentofacial Orthop 2005;128:458-65 www.indiandentalacademy.com
  156. 156. 26. Sivakumar A, Valiathan A. Maxillary midline diastema- A closer look. Kerala Dental Journal 2006; 29(3): 25-26. 27. Ravindra Nanda. (Ed): Biomechanical and Esthetic Strategies in Clinical Orthodontics. Philadelphia, W.B. Saunders and Co.2005: 110-130. www.indiandentalacademy.com
  157. 157. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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