ORTHODONTICS

1. D Y N A M I C S M I L E V I S U A L I Z A T I O N
A N D Q U A N T I F I C A T I O N : P A R T 1 .
E V O L U T I O N O F T H E C O N C E P T
A N D D Y N A M I C R E C O R D S F O R
S M I L E C A P T U R E
D AV I D M . S A R V E R , D M D , M S , A A N D M A R C B .
A C K E R M A N , D M D B
P R E S E N T E D B Y
D E E K S H A B H A N O T I A
U N D E R T H E G U I D A N C E O F
D R . M R I D U L A T R E H A N

2. • 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 include about creating beautiful
smiles.
• Classification schemes have generally based on static morphologic features, such as molar
relationships and the extent of facial divergence.

3. • We focus on the profile because the lateral cephalogram as it is important for orthodontic
treatment planning. As a result of our efforts to be as scientific as possible in our diagnosis and
treatment planning, we have tended to drift away from clinical examination of the patient and
the art of physical diagnosis
• The goal of enhancing patient appearance requires us to revisit fundamental concepts of art and
beauty that were present during the early development of orthodontic doctrine.
• Art played an important role in Angle’s orthodontic school.

4. • Wuerpel, an art professor and a visiting professor in Angle’s school, taught the students about
Greco Roman sculpture and facial proportion.
• Angle originally told Wuerpel, “I want to give my students the finest instruction that I can get
for them.
• When I inquired for an artist who might write for me some fundamental rule which might govern
the character of the faces that came into the hands of my students so that they and I would have
the assurance that all deformity would be corrected, I couldn’t find any one to give me the rule.”
• Wuerpel replied, “Only a fool would reason like that!”
• Thus began a debate between lifelong friends about the need to define individual beauty rather
than to set strict rules based on classical norms.
• There are many advancements made by Angle classifying malocclusion but he didn’t consider
the art for quantifying facial beauty.

5. WHEN DID MODERN ORTHODONTICS DIVERGE FROM ART?
• Advances in orthodontic technology , especially cephalometry has increased the reliance
of measurements and has led to shift away from the diagnosis and treatment plan
• Clinical examination, once the hallmark of orthodontic diagnosis, became secondary to the
information gained from lateral cephalometric radiographs and plaster study models.
• 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.

6. • A smile is defined and described differently by different dental specialists
• Why is there no accepted standard for “smile analysis”?
The primary reason is that the orthodontic specialty has focused its attention on the
multifactorial nature of the smile, combined with a shift toward patient-driven esthetic
diagnosis and treatment planning.
• A century ago, the orthodontic paradigm was geared toward achieving optimal proximal
and occlusal contacts of the teeth within the framework of a balanced profile, along with
acceptable stability, all of which were measured statically.
• The early concepts of esthetics was all about patient’s profile and it was considered that
once ideal tooth jaw positions were achieved, then the soft tissues would fall in line.

7. • In the contemporary orthodontic paradigm, we examine patients in both resting and
dynamic relationships in 3 spatial dimensions and then attempt to harmonize the
discrepancy between their anatomic and physiologic lip–tooth–jaw relationships and their
esthetic and functional desires. In the art of treating the smile, we orthodontists are faced
with a 2-fold task.
• 1st - problem-oriented treatment planning , the orthodontist must establish a diagnosis
that identifies and quantifies which elements of the smile need correction, improvement, or
enhancement.
• Then in the further evolution of the concept of problem oriented diagnosis and treatment
planning ,the positive attributes of a patient’s smile was to be protected as the treatment
problematic aspects were done.

8. • 2nd - visualized treatment strategy must be created to address the patient’s chief
concerns. The complete treatment effort cannot focus solely on unilateral problems, such
as Class II skeletal patterns and open bite, but must include facial balance and smile
esthetics.
• The contemporary orthodontist no longer evaluates patients in terms of only the profile,
but also frontally and vertically, and now a fourth dimension: time is also added.
• The orthodontists are the first in line in a decision-making process that affects a patient’s
appearance for the rest of his or her life. So , not only dento-skeletal growth and
development, but also soft tissue growth, maturation, and aging should ne also considered.

9. • The orthodontist must work with 2 dynamics.
• 1st - Soft tissue repose and animation assessed at the patient’s examination which
includes how the lips animate on smile, gingival display, crown length, and other attributes
of the smile.
• 2nd - Facial change throughout a patient’s lifetime—the impact of skeletal and soft tissue
maturational and aging characteristics.
• Lateral cephalogram is used to do the following diagnosis and treatment plan.

10. • The data generated from measuring the dento-skeletal relationships are a major under
pinning of our treatment decisions to be delivered over 2 years; the dento-skeletal
relationships are expected to be stable for the rest of the patient’s life.
• Scammon’s growth curve is smooth and it represents the variable rates and timing of
physical growth. But this curve represents the average of many data taken over the period .
Sometimes it can fall on the other side of smooth line .
• That’s why the orthodontist begins treatment with therapeutic diagnosis but with a flexible
treatment plan that allows adjustments for unanticipated growth changes or variable
treatment responses during treatment.

11. RECORDS IN TREATMENT OF THE SMILE
• Orthodontic records fall into 3 separate but interdependent categories: static records,
dynamic recordings, and direct biometric measurements.
• In clinical practice, standard records include film or digital photographs, radiographs,
and study models.
• The universal standard for facial images consists of frontal at rest, frontal smile, and
profile at rest images.
• The records needed for contemporary smile visualization and quantification can be divided
into 2 groups: Static and Dynamic

12. • There are 3 facial image orientations, photographic recordings should also include profile and
oblique smile and oblique and frontal smile close-ups.
Profile and oblique facial
smile
Oblique smile close-up
Frontal smile close-up

13. • The dynamic recording of smile and speech 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.
• We typically take 5 seconds of video for each patient, yielding 150 frames for comparison and the
videos are recorded in standardized fashion with the camera at a fixed distance from the subject.
• One segment taken in - frontal view
Another segment taken in- oblique view.
• These clips, taken before and after treatment for all patients, allow us to use matched frames to
analyse the changes in smile characteristics.

14. • The patient’s head is placed in a cephalometric head holder to obtain natural head position,
and the patient is asked to rehearse the phrase “Chelsea eats cheesecake on the
Chesapeake,” and then to smile.
• The video is downloaded to the computer, and the video clip is compressed. Each clip is
approximately 4 MB.
• The video clip is reviewed, and the frame that best represents the patient’s natural
unstrained social smile is selected.

15. • Dynamic digital video clips helps to understand the type of smile patient exhibits. According to
the classification of Rubin, there are 3 smile styles.
1. Commissure smile - corners of the mouth turn upward due to the pull of the zygomaticus
major muscles. Also called “the Mona Lisa smile.”
2. Cuspid smile- upper lip is elevated uniformly without the corners of the mouth turning
upward; the entire lip rises like a window shade.
3. Complex smile- upper lip moves superiorly, as in the cuspid smile, but the lower lip also
moves inferiorly in a similar fashion.
Commissure smile Cuspid Smile Complex smile

16. 1 -Commissure height
2- Philtrum height
3- Inter labial gap and incisor
show at rest
• Direct measurement permits the clinician to quantify resting and dynamic lip–tooth
relationships. So, the following frontal measurements should be performed systematically
Philtrum height
Commissure height
Inter labial gap
Incisor show at rest and smile
Crown height
Gingival displace
Smile arc.
DIRECT MEASUREMENT AS A BIOMETRIC TOOL

17. 1 -Commissure height
2- Philtrum height
3- Inter labial gap and incisor
show at rest
• Philtrum height - From subspinale to the most inferior portion of the upper lip on the
vermilion tip beneath the philtral columns.
• Commissure height - From a line constructed from the alar bases through subspinale, and
then from the commissures perpendicular to this line.
• Inter labial gap - Distance between the upper and lower lips when lip incompetence is
present.

18. Systematic measurements of dynamic relationships
include
1 Crown height
2 Gingival display
3 Smile arc relationships.
• 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.
• The amount of gingival display on smile that is acceptable esthetically can vary widely, but
the relationship between gingival display and incisor show at rest is important that is a gummy
smile is often more esthetic than a smile with less tooth display.
.

19. • 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.
• Ideal smile arc, the curvature of the maxillary incisal edge is parallel
to the curvature of the lower lip upon smile
• Consonant describes this parallel relationship.
• Nonconsonant or flat smile, the maxillary incisal curvature is flatter
than the curvature of the lower lip on smile.
Ideal smile arc has maxillary
incisal edge curvature parallel to
curvature of lower lip upon
smile; term consonant is used to
describe this parallel relationship

20. CASE ILLUSTRATION
• This case demonstrates how important it is to assess soft tissue resting and dynamic
relationships in achieving superior esthetic results in orthognathic and orthodontic cases.
• This patient was referred for treatment of anterior open bite and vertical maxillary excess
through combined orthodontic therapy and orthognathic surgery.
• At rest, she clearly had a short philtrum height relative to the commissures with a reverse
resting lip posture, resembling a frown as shown in this figure.

21. • The short philtrum also contributed to her excessive gingival display of 8 mm on smile as
shown this figure.
• A previous orthognathic procedure had fallen short of the desired result, and she sought
further consultation. An anterior open bite of 3 mm was present , so a LeFort I osteotomy
was recommended to achieve bite closure.

22. • The systematic evaluations of the upper lip–tooth resting and dynamic relationships were
as follows
1. Philtrum height (25 mm) was 7 mm shorter than commissure height (32 mm)
2. Incisor crown height was 8 mm;
3. At rest, 8 mm of incisor showed;
4. On smile, 100% of the incisors showed;
5. Gingival display was 8 mm

23. • Evaluating the relationship of the maxillary incisor to the upper lip at rest and on smile
resulted in the following treatment plan –
1 )Periodontal crown lengthening
to improve crown height and dimensional proportionality and to reduce the amount of
gingival display on smile (3 mm additional crown height was achieved).
2. Orthognathic surgery with combined and simultaneous maxillary impaction, rhinoplasty,
and V-Y cheiloplasty to lengthen the upper lip.

24. • V-Y cheiloplasty and rhinoplasty lengthen the philtrum (3 mm) and provide some lip
immobilization due to the orientation of the incisions and lip repositioning.
• Maxillary impaction of 3 mm posteriorly and only 2 mm anteriorly would close the bite.
• The soft tissue procedures would dramatically decrease the amount of maxillary impaction
needed to achieve ideal smile esthetics; this was highly desirable because of the patient’s
round face proportionality.

25. • Our patient’s final resting relationships were greatly improved , with lip competence, an
attractive cupid’s bow, improvement in the philtrum length relative to the commissures,
and more ideal vermilion show of the upper lip relative to the lower lip. All the desired
attributes of an improved smile were also attained .

26. CONCLUSION
• Visualization and quantification of the dynamics of the smile is a 2-stage process.
• The first crucial step is the clinical examination.
• The key element in this evaluation is the direct measurement of lip–tooth relationships
both dynamically and in repose.
• Record taking is the second step in this process.
• We use digital photography, digital videography, radiography, and plaster study casts
to accurately record the dynamic and static attributes of a patient’s smile. These
records are taken frontally and obliquely to allow for a 3-dimensional description of
smile characteristics.
• From this database, one can then perform a smile analysis.

27. HULSEY CM. AN ESTHETIC EVALUATION OF LIP-TEETH
RELATIONSHIPS PRESENT IN THE SMILE. AM J ORTHOD
1970;57:132-44.
This study was initiated in an attempt to obtain some information about two questions:
(I) Are the smiles of orthodontically treated patients as attractive as those of persons with
“normal occlusion”?
(2) What relationship between the lips and teeth, if any exists, should the orthodontist
consider in positioning the anterior teeth during orthodontic treatment?

28. • Forty subjects twenty with orthodontically treated occlusions and twenty with “normal
occlusions,” were evaluated.
• There were ten male and ten female subjects in each group.
• Standardized black and white photographs of their smiles, with the areas surrounding the
smiles masked out, were evaluated by a panel of ten men and ten women.
• No photographs of the smiles of patients prior to orthodontic therapy were used.

29. • Five basic components of each smile were studied:
(1) the smile line ratio, that is, the congruency of the arc of curvature of the upper border of
the lower lip and the arc of curvature of the incisal edges of the upper anterior teeth;
(2) the smile symmetry ratio, whether or not the lips on each side of the smile midline were
symmetrical with each other;
(3) the buccal corridor ratio, the ratio of the width between the canine teeth to the width of
the smile;
(4) the height of the upper lip, determined by the relationship of the upper lip to the gingival
margin of the upper centra.1 incisor;
(5) the curvature of the upper lip, whether or not the corners of the smile were above, even
with, or below the midline of the upper lip.

30. • The following observations were made:
1. As a result of the panel members’ evaluations, orthodontically treated subjects had
significantly poorer smile scores than the subjects with “normal occlusion.”
2. The smile line ratio appeared to be of importance to an attractive smile, and the most
attractive smile displayed a smile line ratio of 1.00 to 1.25 or near perfect harmony between
the ares of curvature of the incisal edges of the upper incisors and the upper border of the
lower lip.
3. The smile symmetry ratio was revealed in this study to be important to a good smile, since
no smiles that were asymmetrical had high smile scores.

31. 4. The buccal corridor ratio appeared to be of no significance to an attractive smile.
5. The height of the upper lip to the upper central incisor influenced the rating of the smile,
the most attractive smiles having the upper lip at the height of the gingival margin of the
upper central incisor.
6. In the subjects studied, the upper lip curvature was most desirable when the corners of the
smile were above the midline of the upper lip.

32. • However, those smiles in which the corners of the smile were below the midline of the
upper lip were attractive if they possessed the most desirable relationships of each of the
other components.
• Further evaluation of these and other components of the smile should lead to the
development of a “smile index,” so that the orthodontist may be better able to give the
patient an “ideal smile” which would be an expression of the optimum in facial esthetics
for that individual.